Ocular implant containing a tyrosine kinase inhibitor

ABSTRACT

The invention relates to a sustained release biodegradable ocular implant containing a tyrosine kinase inhibitor dispersed in a hydrogel for the treatment of a retinal disease for an extended period of time.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present invention claims priority to U.S. Provisional ApplicationSer. No. 62/994,391 filed Mar. 25, 2020, to International ApplicationPCT/US2020/029827 filed 24 Apr. 2020, to U.S. Provisional ApplicationSer. No. 63/106,276 filed Oct. 27, 2020, and to U.S. ProvisionalApplication Ser. No. 63/148,463 filed Feb. 11, 2021, which are allhereby incorporated by reference herein.

TECHNICAL FIELD

The present invention relates to the treatment of ocular diseases, forexample neovascular age-related macular degeneration (AMD), alsoreferred to as “wet AMD”. According to the present invention, oculardiseases are treated by administering an injection (e.g.,intravitreally) of an implant that is biodegradable and providessustained release of a tyrosine kinase inhibitor such as axitinib.

BACKGROUND

Macular diseases, including AMD, are among the leading causes of visualimpairment and irreversible blindness in the world for people over theage of 50. Specifically, AMD was one of the most common retinal diseasesin the United States (US) in 2019, affecting approximately 16.9 millionpeople, and this is expected to grow to 18.8 million people in 2024(Market Scope. Ophthalmic Comprehensive Reports. 2019 RetinalPharmaceuticals Market Report: A Global Analysis for 2018 to 2019,September 2019). AMD can be subdivided into different disease stages.Early AMD is characterized by the presence of a few (<20) medium-sizedrusen or retinal pigmentary abnormalities. Intermediate AMD ischaracterized by at least one large druse, numerous medium-size drusen,or geographic atrophy that does not extend to the center of the macula.Advanced or late AMD can be either non-neovascular (dry, atrophic, ornon-exudative) or neovascular (wet or exudative). Advancednon-neovascular AMD is characterized by drusen and geographic atrophyextending to the center of the macula. Advanced neovascular AMD ischaracterized by choroidal neovascularization and its sequelae (Jager etal., Age-related macular degeneration. N Engl J Med. 2008;358(24):2606-17).

The more advanced form of wet AMD is characterized by an increase invascular endothelial growth factor (VEGF), which promotes the growth ofnew vessels (angiogenesis) that grow beneath the retina and leak bloodand fluid into and below the macular and subretinal space. Successfulinterference of this pathway has been achieved with the development ofinhibitors of vascular endothelial growth factor subtypes, i.e., VEGFinhibitors, initially used to treat various cancers. Photodynamictherapy in combination with anti-VEGF and steroid administration arecurrently reserved as a second-line therapy for patients not respondingto monotherapy with an anti-VEGF agent (Al-Zamil et al., Recentdevelopments in age-related macular degeneration: a review. Clin InteryAging. 2017; 12:1313-30).

Other common retinal diseases are diabetic macular edema (DME) andretinal vein occlusion (RVO). DME was one of the most common retinaldiseases in the US in 2019, affecting approximately 8 million people,and this is expected to grow to 8.8 million people in 2024 (Market Scope2019, supra). The condition is categorized by a decrease in retinaltension and an increase in vascular pressure caused by the upregulationof VEGF, retinal vascular autoregulation (Browning et al., Diabeticmacular edema: evidence-based management. 2018 Indian journal ofophthalmology, 66(1), p. 1736) and inflammatory cytokines and chemokines(Miller et al., Diabetic macular edema: current understanding,pharmacologic treatment options, and developing therapies. 2018,Asia-Pacific Journal of Ophthalmology, 7(1):28-35). The changes thatoccur from these inflammatory and vasogenic mediators result in thebreakdown of the blood retinal barrier (BRB) in the vascular endothelium(Miller et al, supra). Hard exudates enter into the extracellular spacecausing blurred and distorted central vision, resulting in a decrease inthe patient's visual acuity (Schmidt-Erfurth et al., guidelines for theManagement of Diabetic Macular Edema by the European Society of RetinaSpecialists (EURETINA). 2017, Ophthalmologica. 237(4): 185-222). Onaverage, a patient will experience an 8% decrease in visual acuity after3 years following the start of the condition.

The basis of all available treatments for DME is to try to control themetabolic functions of hyperglycemia and blood pressure (Browning etal., supra). Anti-VEGF therapy is currently considered a first linetherapy in the standard of care treatment of DME as it is proven to beless destructive and damaging than other treatment methods(Schmidt-Erfurth et al., supra). The pharmacological route is beneficialbecause the drugs are manufactured to specifically target VEGF pathwaysand inhibit the upregulation that occurs with DME (Miller et al.,supra). Other treatment options include intravitreal corticosteroidinjections, focal laser photocoagulation, and vitrectomy (Browning etal., supra).

RVO affected approximately 1.3 million people in the US in 2019 and ispredicted to affect 1.4 million people in the US in 2024 (Market Scope2019, supra). RVO is a chronic condition in which the retinalcirculation contains a blockage leading to leakage, retinal thickening,and visual impairment (Ip and Hendrick, Retinal Vein Occlusion Review.2018, Asia-Pacific Journal of Ophthalmology, 7(1):40-45; Pierru et al.,Occlusions veineuses rétiniennes retinal vein occlusions. 2017, JournalFrancais d′Ophtalmologie, 40(8):696-705). The condition is typicallyseen in patients 55 and older who have a pre-existing condition such ashigh blood pressure, diabetes, and glaucoma. RVO does not have aprojected course as it can either deteriorate a patient's vision quicklyor remain asymptomatic. Prognosis of RVO and associated treatmentoptions depend on the classification of the disease as the differentvariants have different risk factors despite behaving similarly.Classification of the disease is categorized depending on the locationof the impaired retinal circulation: branch retinal vein occlusion(BRVO), hemiretinal vein occlusion (HRVO), and central retinal veinocclusion (CRVO). BRVO is more common affecting 0.4% worldwide and CRVOaffecting 0.08% worldwide. Studies show that BRVO is more prevalent inAsian and Hispanic groups compared to Caucasians (Ip and Hendrick,supra).

Treatment of RVO currently includes symptomatic maintenance of thecondition to avoid further complications, macular edema, and neovascularglaucoma. Anti-VEGF treatment is currently the standard of caretreatment and may temporarily improve vision. Other treatment optionsinclude lasers, steroids, and surgery (Pierru et al., supra).

Anti-VEGF agents are currently considered the standard of care treatmentfor wet AMD, DME, and RVO. The first treatment approved for wet AMD bythe FDA in 2004 was MACUGEN® (pegaptanib sodium injection by Bausch &Lomb). Since then, LUCENTIS® (ranibizumab injection by Genentech, Inc.)and EYLEA® (aflibercept injection by Regeneron Pharmaceuticals, Inc.)have been approved for the treatment of wet AMD in 2006, and 2011respectively, as well as DME and macular edema following RVO.Additionally, in October 2019, BEOVU® (brolucizumab injection byNovartis Pharmaceuticals Corp) was approved by the FDA for the treatmentof wet AMD. Other developments are reported in Amadio et al., TargetingVEGF in eye neovascularization: What's new?: A comprehensive review oncurrent therapies and oligonucleotide-based interventions underdevelopment. 2016, Pharmacological Research, 103:253-69.

However, despite these advancements, there are limitations to anti-VEGFtreatment. Most patients currently require multiple injections (such asmonthly) essentially for the rest of their lives due to rapid vitreousclearance. Moreover, not all patients respond to anti-VEGF treatment.Additionally, these treatment options further have potential risksassociated with administration including infection, macular atrophy,loss of vision over time, retinal detachment and elevated intraocularpressure (IOP). Patient complaints include discomfort, eye pain,decreased vision, and increased photosensitivity. In addition to theburden on the patient and risks associated with frequent injections,there are other limitations that are known to be associated with currentanti-VEGF treatments such as the potential risk of immunogenicity,complex manufacturing requirement of biologics, macular atrophy, andretinal vasculitis. Importantly, regardless of the number ofmedications, patients are currently expected to remain on treatmentindefinitely.

Tyrosine kinase inhibitors were developed as chemotherapeutics thatinhibit signaling of receptor tyrosine kinases (RTKs), which are afamily of tyrosine protein kinases. RTKs span the cell membrane with anintracellular (internal) and extracellular (external) portion. Uponligand binding to the extracellular portion, receptor tyrosine kinasesdimerize and initiate an intracellular signaling cascade driven byautophosphorylation using the coenzyme messenger adenosine triphosphate(ATP). Many of the RTK ligands are growth factors such as VEGF. VEGFrelates to a family of proteins binding to VEGF-receptor (VEGFR) types,i.e. VEGFR1-3 (all RTKs), thereby inducing angiogenesis. VEGF-A, whichbinds to VEGFR2, is the target of the anti-VEGF drugs described above.Besides VEGFR1-3 several other RTKs are known to induce angiogenesissuch as platelet-derived growth factor receptor (PDGFR) activated byPDGF or stem cell growth factor receptor/type III receptor tyrosinekinase (c-Kit) activated by stem cell factor.

Some TKIs have been evaluated for the treatment of AMD via differentadministration routes, including pazopanib (GlaxoSmithKline:NCT00463320), regorafenib (Bayer: NCT02348359), and PAN90806 (PanOptica:NCT02022540) all administered as eye drops, as well as X-82, an oral TKI(Tyrogenex; NCT01674569, NCT02348359). However, topically applied eyedrops result in poor penetration into the vitreous and limiteddistribution to the retina due to low solution concentration of TKIs,which tend to have low water solubility, and short residence time of theTKIs on the ocular surface. Moreover, drug concentration upon topicaladministration is difficult to control due to wash out or user error.Furthermore, systemic administration of TKIs is not practicable, as highdoses are required to achieve effective concentrations of the drug inthe eye and particularly at the desired tissue. This leads tounacceptable side effects due to high systemic exposure. In addition,drug concentrations are difficult to control. Alternatively,intravitreal injections of TKI suspensions have been performed. However,this way of administration results in rapid clearance of the drug andtherefore injections have to be repeated frequently, such as on a dailyor at least a monthly basis. In addition, several TKIs are poorlysoluble which leads to the formation of aggregates upon intravitrealinjection, which can migrate or settle onto the retina and lead to localcontact toxicity and holes, such as macular or retinal holes.

Thus, there is an urgent need for an improved treatment of oculardiseases such as AMD, DME, and RVO with TKIs, which is effective over anextended period of time avoiding the need for frequent (monthly or evendaily) injections which are currently required for common anti-VEGFtherapies, especially for individuals not responding to anti-VEGFtherapies (e.g. up to 33% of subjects with DME).

All references disclosed herein are hereby incorporated by reference intheir entireties for all purposes.

OBJECTS AND SUMMARY OF THE INVENTION

It is an object of certain embodiments of the present invention toprovide an ocular implant comprising a tyrosine kinase inhibitor (TKI)such as axitinib that is effective for treating ocular diseases such asneovascular age-related macular degeneration (AMD), DME, and RVO in apatient for an extended period of time.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a tyrosine kinase inhibitor (TKI)such as axitinib that provides for sustained release of the TKI into theeye.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that ispre-loaded into a syringe, thereby avoiding contamination of the implantprior to injection as no further preparation steps are needed.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that issufficiently biodegradable, i.e., cleared from the eye within a timecoinciding with TKI release, avoiding floaters within the patient's eye(empty implant vehicle residues) and/or avoiding the need for removal ofthe empty implant from the eye after the treatment period.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that isbiodegradable, wherein decomposition of the implant into smallerparticles that may e.g. impact vision are avoided during implantdegradation.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib, wherein thestability of the ocular implant is less affected by varying environmentsin the eye such as vitreous humor viscosity, pH of the vitreous humor,composition of the vitreous humor and/or intraocular pressure (IOP) whencompared to hydrogels formed in situ after injection.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that isbiocompatible and non-immunogenic due to the implant being free orsubstantially free of animal- or human-derived components.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that is freeof preservatives, such as antimicrobial preservatives.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that is easyto inject, in particular intravitreally.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatcontains a therapeutically effective amount of said TKI but isrelatively small in length and/or diameter.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that isdimensionally stable when in a dry state but changes its dimensions uponhydration, e.g. after administration to the eye.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that has asmall diameter when in a dry state to fit into the lumen of afine-diameter needle (such as a 22- to 30-gauge needle) and increases indiameter but decreases in length upon hydration, e.g. afteradministration to the eye; thus, providing a minimally invasive methodof administration.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that isinjected in a dry form and hydrates in situ (i.e. in the eye) wheninjected.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that whenplaced in the eye has low TKI concentration at the implant surfacethereby avoiding toxicity of the TKI when the implant gets in contactwith ocular cells or tissues such as the retina.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that isstable and has a defined shape and surface area both in a dry stateprior to as well as in a hydrated state after the injection (i.e. insidethe eye).

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that is easyto handle, in particular that does not spill or fragment easily.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that enablesadministration of an exact dose (within a broad dose range), therebyavoiding the risk of over- and under-dosing.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatgenerally stays in the area of the eye to which it was administered.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib, wherein theimplant causes minimal or no visual impairment after administration.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that is safeand well tolerated.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib that doesnot induce severe adverse events, such as severe ocular adverse events.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides for sustained release of a therapeutically effective amount ofthe TKI such as axitinib over an extended period of time, such as over aperiod of up to 3 months or longer, such as at least 6, at least 9, atleast 11 months, or at least 13 months.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides for sustained release of a TKI such as axitinib over anextended period of time, such as over a period of up to 3 months orlonger, such as at least 6, at least 9, at least 11 months, or at least13 months, thereby avoiding the need for frequent implantadministrations.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides for sustained release of the TKI such as axitinib over anextended period of time, such as over a period of up to 3 months orlonger, such as at least 6, at least 9, at least 11 months, or at least13 months, thereby inhibiting angiogenesis over this period of time.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides for sustained release of the TKI over an extended period oftime, such as over a period of up to 3 months or longer, such as atleast 6, at least 9, at least 11 months, or at least 13 months, whereinthe TKI levels in ocular tissues such as the retina and the choroid, aswell as the vitreous humor are consistently maintained at atherapeutically efficient level, in particular at a level sufficient forinhibition of angiogenesis, over this period of time.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides for sustained release of a TKI such as axitinib over anextended period of time, such as over a period of up to 3 months orlonger, such as at least 6, at least 9, at least 11 months, or at least13 months, wherein no toxic concentrations of the TKI are observed inocular tissues such as the retina and the choroid, as well as thevitreous humor over this period of time.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides for sustained release of a TKI such as axitinib over anextended period of time, such as over a period of up to 3 months orlonger, such as at least 6, at least 9, at least 11 months, or at least13 months, wherein the TKI is not accumulating in the anterior chamberof the eye.

Another object of certain embodiments of the present invention is toprovide an ocular implant comprising a TKI such as axitinib thatprovides sustained release of a TKI over an extended period of time,such as over a period of up to 3 months or longer, such as at least 6,at least 9, at least 11 months, or at least 13 months, wherein the TKIis not or is not substantially resorbed systemically therebysubstantially avoiding systemic toxicity.

Another object of certain embodiments of the present invention is toprovide a method of treating ocular diseases such as AMD, DME, and RVOin a patient in need thereof, for a treatment period of up to 3 monthsor longer, such as at least 6, at least 9, at least 11 months, or atleast 13 months.

Another object of certain embodiments of the present invention is toprovide a method of treating ocular diseases such as AMD, DME, and RVOin a patient in need thereof, for a treatment period of up to 3 monthsor longer, such as at least 6, at least 9, at least 11 months, or atleast 13 months, without the need for the administration of rescuemedication during the treatment period, or wherein rescue medication isrequired to be administered only rarely, such as 1, 2 or 3 times, duringthe treatment period.

Another object of certain embodiments of the present invention is toprovide a method of treating ocular diseases such as AMD, DME, and RVOin a patient in need thereof, such as a patient who has been treatedwith anti-VEGF before or a patient who is naïve for anti-VEGF treatment.

Another object of certain embodiments of the present invention is toprovide a method of treating ocular diseases such as AMD, DME, and RVOin a patient in need thereof, such as a patient who has been treatedwith anti-VEGF before and has not responded to the previous anti-VEGFtreatment.

Another object of certain embodiments of the present invention is toprovide a method of treating ocular diseases such as AMD, DME, and RVOin a patient in need thereof, such as a patient with a diagnosis ofprimary subfoveal neovascularization (SFNV) secondary to AMD.

Another object of certain embodiments of the present invention is toprovide a method of treating ocular diseases such as AMD, DME, and RVOin a patient in need thereof, such as a patient with a diagnosis ofpreviously treated subfoveal neovascularization (SFNV) secondary toneovascular AMD with leakage involving the fovea, who has beenpreviously treated with anti-VEGF.

Another object of certain embodiments of the present invention is toprovide a method of manufacturing an ocular implant comprising a TKIsuch as axitinib.

Another object of certain embodiments of the present invention is toprovide a method of protecting an ocular implant from prematurehydration during storage and handling, wherein the ocular implant issensitive to moisture such that it for instance changes its dimensionsupon hydration.

Another object of certain embodiments of the present invention is toprovide a method of minimizing potential tissue damage during injectionof an ocular implant.

Another object of certain embodiments of the present invention is toprovide a kit comprising one or more ocular implants comprising a TKIsuch as axitinib and optionally comprising a means for injecting theocular implant.

Another object of certain embodiments of the present invention is toprovide a method of reducing the central subfield thickness as measuredby optical coherence tomography in a patient whose central subfieldthickness is elevated due to an ocular disease involving angiogenesis byfor instance reducing retinal fluid.

Another object of the present invention is to provide a method ofessentially maintaining or preventing a clinically significant increaseof the central subfield thickness as measured by optical coherencetomography in a patient whose central subfield thickness is elevated dueto an ocular disease involving angiogenesis while not increasing retinalfluid.

Another object of certain embodiments of the present invention is toprovide a method of reducing, essentially maintaining or preventing aclinically significant increase of the central subfield thickness asmeasured by optical coherence tomography in a patient whose centralsubfield thickness is elevated due to an ocular disease involvingangiogenesis while improving or at least not impairing the patient'svisual acuity as measured for instance by means of best corrected visualacuity.

Another object of certain embodiments of the present invention is toprovide a method of improving the vision of a patient whose vision isimpaired due to an ocular disease involving angiogenesis.

Another object of certain embodiments the present invention is toprovide a method of improving the vision of a patient whose vision isimpaired due to the presence of retinal fluid (caused for instance by anocular disease involving angiogenesis) by means of reducing retinalfluid in the patient (as for instance evidenced by a reduction thecentral subfield thickness as measured by optical coherence tomography).

One or more of these objects of the present invention and others aresolved by one or more embodiments as disclosed and claimed herein.

The individual aspects of the present invention are disclosed in thespecification and claimed in the independent claims, while the dependentclaims claim particular embodiments and variations of these aspects ofthe invention. Details of the various aspects of the present inventionare provided in the detailed description below.

Throughout this application various references are cited. Thedisclosures of these references are hereby incorporated by referenceinto the present disclosure. In case of conflict, the disclosure in thepresent application prevails.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 Schematic representation of one embodiment of the implantpackaging. In this embodiment, implants are pre-loaded into thin-walledneedles separately packaged from the injection device. An all-in-onedevice with needles already connected to the injection device is alsopossible.

FIG. 2 Schematic representation of one embodiment of implantlocalization. After injection the implant hydrates in situ whilemaintaining a cylindrical shape. The implant is localized in theposterior part of the eye.

FIG. 3 Schematic representation of hydrogel biodegradation over time. Asthe drug is released, a clearance zone is formed (black) as lowsolubility drug particles (white) gradually dissolve and drug diffusesfrom hydrogel to the aqueous surrounding (as for instance the vitreoushumor). Over time, the gel degrades and is resorbed, while drug diffusesout. During the degradation process, the gel gradually swells untildegradation is advanced to the point of shrinkage and distortion.

FIG. 4A and FIG. 4B One embodiment of in vitro axitinib release per dayfor different implants. FIG. 4A In vitro axitinib release under non-sinkdissolution conditions from different implants, comprising an axitinibdose of 625, 716, 245, and 490 (2×245) pg. FIG. 4B In vitro acceleratedaxitinib release from a 556 μg implant.

FIG. 5A and FIG. 5B One embodiment of low dose study in rabbits. FIG. 5AInfrared reflectance (IR) of 1, 2, and 3 implants in rabbits one monthpost injection. The overall shape of the implants remained intactindependent of the number of implants administered. FIG. 5B Vascularleakage was efficiently suppressed for all three doses (15, 30, and 45μg) after 1 month, while vascular leakage was high for the controlanimals without implant. Error bars represent standard deviation (SD;solely upper error bars presented).

FIG. 6 One embodiment of infrared reflectance (IR) and optical coherencetomography (OCT) imaging of rabbit eyes. IR/OCT images of retinalmorphology after 1, 3, and 6 months after implant injection,respectively. Retinal morphology was normal.

FIG. 7A and FIG. 7B One embodiment of biodegradation of implant andinflammation. FIG. 7A Significant biodegradation of the hydrogelcomponent of the implant in rabbit eye was observed over time. At weeks4 and 8 after injection the implant was still intact, whereas at week 12early stages of hydrogel degradation were visible. Implant was furthernarrowed at week 16 due to loss of hydrogel structure. Finally, hydrogelwas absent after 20 and 26 weeks and free (undissolved) axitinibparticles (white specs) were visible in proximity to the former implantsite. FIG. 7B Histopathological analysis demonstrated no inflammationafter 26 weeks in regions of undissolved axitinib. Images are presentedat 20× magnification (scale: 1000 μm) and 200× magnification (scale: 100μm).

FIG. 8 One embodiment of suppression of vascular leakage in rabbitschallenged with VEGF following administration of an axitinib implantwith a dose of 227 μg. Vascular leakage scores (0 (normal) to 4 (severeleakage)) are presented in dependency of the time (months) after VEGFchallenge for animals with and without the implant. Effectivesuppression of vascular leakage was observed for animals having theimplant for a duration of 6 months. Error bars represent standarddeviation (SD; solely upper error bars presented).

FIG. 9 One embodiment of infrared reflectance (IR) imaging of twoimplants in rabbit eyes. Implants show degradation over time. Implantswere intact at days 27 to 117, while implant narrowing was observed dueto hydrogel degradation observed on days 141 and 195. Remaining axitinibparticles merged into a single monolithic structure on days 141 and 195.Free axitinib particles (white specs) were noted in proximity to theformer implant site post hydrogel degradation.

FIG. 10 One embodiment of infrared reflectance (IR) imaging of twoimplants in rabbit eyes. The implant was intact during 0.5 to 3 monthsafter injection. After 6 months, the implant narrowed due to hydrogeldegradation and remaining axitinib particles merged into a singlemonolithic structure. Free axitinib particles (white specs) were notedin proximity to the former implant site post hydrogel degradation at 24months up to 38 months.

FIG. 11 One embodiment of suppression of vascular leakage in rabbitschallenged with VEGF following administration of two axitinib implantswith a total dose of 290 μg without (group 1) and with (group 2)co-administration of Avastin®. Vascular leakage scores (0 (normal) to 4(severe leakage)) are presented in dependency of the time (months) afterVEGF challenge for animals from group 1 and 2 and for animals without animplant. Significant suppression of vascular leakage was observed forall groups of animals having the implants. Error bars represent standarddeviation.

FIG. 12 One embodiment of fluorescein angiography (FA) images revealedsignificant leakage, with fluorescein seen actively leaking fromvasculature immediately following injection of fluorescein 48 hoursafter the VEGF challenge in the control animals (upper panel) andcomplete inhibition of leakage from vessels of rabbit eyes comprisingthe implants (lower panel). Images were collected after VEGF challenge 1month after the implant injection.

FIG. 13 One embodiment of average vascular leakage score for rabbitswhich were not treated with implant or anti-VEGF therapeutic (whitesquares and dashed line), rabbits which were treated with Avastin® only(black triangles, curve fit until 3 months), rabbits with implants(black squares, solid line until 12 months), and rabbits with implantsand Avastin® (striped squares and dashed line until 12 months). Vascularleakage was efficiently inhibited for 12 months for all animals thatreceived the implants. Animals solely treated with anti-VEGF therapeuticshowed rapid onset of leakage inhibition in the first 2 to 4 weeks, butleakage re-occurred after 3 months. Values represent mean and standarderror of the mean (SEM).

FIG. 14A and FIG. 14B One embodiment of in vitro axitinib release from a200 μg implant. FIG. 14A) Axitinib was completely released from the 200μg implant after 225 days as observed by the in vitro real-time assay.FIG. 14B Axitinib was completely released from the 200 μg implant after12 days as observed by the in vitro accelerated assay. In vitro datawere not indicated for in vivo release observed.

FIG. 15 One embodiment of IR images of subject #1 from cohort 2 (2implants, 400 μg axitinib in total per eye). Implants are clearlyvisible and well-shaped on the injection day. After 9 months, implantsare fully degraded while undissolved axitinib is remaining at the formerimplant locations. The undissolved axitinib continues to release drug,while after 11 months almost no undissolved axitinib is left.

FIG. 16 One embodiment of spectral domain optical coherence tomography(SD-OCT) images from the study eye of subject #1 of cohort 1 (1 implant,200 μg axitinib in total per eye). For this treatment naïve subject asignificant reduction in central subfield thickness (CSFT) was observedwhile best corrected visual acuity (BCVA) was not impaired over 10.5months.

FIG. 17 One embodiment of central subfield thickness (CSFT) in the studyeyes of patients suffering from neovascular age-related maculardegeneration (wet AMD) treated with axitinib implants (one implant,total dose of 200 μg: cohort 1; two implants, total dose of 400 μg:cohort 2; three implants, total dose of 600 μg: cohort 3a; two implants,total dose of 400 μg and concurrent initial anti-VEGF: cohort 3b).Presented in this chart are mean changes in CSFT with standard error ofthe mean (SEM) compared to the baseline value. For this chart: Sixpatients were followed in cohort 1 until month 9. Seven patients werefollowed in cohort 2 until month 12, five until month 14 and two untilmonth 16. Six patients were followed in cohort 3a until day 14, fiveuntil month 2, two until month 4.5, and one until months 6 and 7.5. Twopatients were followed in cohort 3b until month 3, and one until month4.5. Follow-up is ongoing.

FIG. 18 One embodiment of best corrected visual acuity (BCVA) in thestudy eyes of patients suffering from neovascular age-related maculardegeneration (wet AMD) treated with axitinib implants (one implant,total dose of 200 μg: cohort 1; two implants, total dose of 400 μg:cohort 2; three implants, total dose of 600 μg: cohort 3a; two implants,total dose of 400 μg and concurrent initial anti-VEGF: cohort 3b).Presented in this chart are mean changes in BCVA with standard error ofthe mean (SEM) compared to the baseline value in Early TreatmentDiabetic Retinopathy Study (ETDRS) Letter Score (a representative valuefor letters that can be read correctly at a certain distance). For thischart (as for FIG. 17 above): Six patients were followed in cohort 1until month 9. Seven patients were followed in cohort 2 until month 12,five until month 14 and two until month 16. Six patients were followedin cohort 3a until day 14, five until month 2, two until month 4.5, andone until months 6 and 7.5. Two patients were followed in cohort 3buntil month 3, and one until month 4.5. Follow-up is ongoing.

FIGS. 19A and 19B One embodiment of spectral domain optical coherencetomography (SD-OCT) images from the study eye of subject #1 of cohort 2(2 implants, 400 μg axitinib in total per eye) with aflibercepttreatment history of 16 months prior to injection of the implants in theright eye (OD). Sub-retinal fluid was clearly visible at baseline(pre-treatment). Importantly, the sub-retinal fluid was gone after 2-3months after implants injection and this stage was essentiallymaintained over 15.5 months (15.5 months shown in FIG. 19B, the earliervisits in FIG. 19A). Best corrected visual acuity (BCVA) was notimpaired.

FIG. 20 One embodiment of spectral domain optical coherence tomography(SD-OCT) images from subject #7 of cohort 2 (2 implants, 400 μg axitinibin total per eye). Subject #7 who had received aflibercept for 6 yearsprior to study start showed significant reduction in CSFT and noimpairment of BCVA for 9 months after implant injection.

FIG. 21 One embodiment of spectral domain optical coherence tomography(SD-OCT) images from subject #1 of cohort 3a (3 implants, 600 μgaxitinib in total per eye). A significant reduction in CSFT was observedat 2 months and maintained for 7.5 months in subject #1 from cohort 3awho was naïve for AMD treatment. BCVA was not impaired.

FIG. 22 One embodiment of spectral domain optical coherence tomography(SD-OCT) images from subject #1 from cohort 3b (2 implants, 400 μgaxitinib in total per eye including co-administration of an anti-VEGFagent), who was anti-VEGF treatment naïve. CSFT was rapidly reducedwithin 7 days and further reduced and maintained low until month 3.

FIG. 23 One embodiment of spectral domain optical coherence tomography(SD-OCT) images from subject #2 from cohort 3b (2 implants, 400 μgaxitinib in total per eye including initial co-administration of ananti-VEGF agent), who had received anti-VEGF treatment for 7 monthsprior to implant injection. CSFT was rapidly reduced within 7 days. Thelow CSFT value was maintained until month 2.

FIG. 24 One embodiment of the agglomeration tendency of axitinib whenpreparing and casting a hydrogel implant according to an embodiment ofthe invention using micronized vs. non-micronized axitinib underotherwise identical conditions.

FIG. 25A, FIG. 25B and FIG. 25C One embodiment of an injector accordingto the present invention for injecting an implant into the vitreoushumor of a patient. This depicted embodiment of an injector comprises aHamilton syringe body and a Nitinol push wire to deploy the implant.FIG. 25A shows the Hamilton syringe body inside of an injection moldedcasing. FIG. 25B shows the injection molded casing without the Haimltonsyringe body therein. FIG. 25C shows an exploded view of the componentsof this embodiment of the injector.

FIG. 26A Exploded view diagram of one embodiment of an injectoraccording to the present invention that is made of an injection moldedbody. FIG. 26B shows a photograph of the fully assembled injector. FIG.26C shows an exploded view of a first assembly of an injector accordingto the present invention. FIG. 26D shows an exploded view of a secondassembly of an injector according to the present invention. FIG. 26Eshows that the first and the second assembly can be aligned. FIG. 26Fshows the cowl of the second assembly being secured to the body of thefirst assembly. FIG. 26G shows the needle shield being removed from thecowl of the second assembly and the plunger clip being removed from thebody and plunger of the first assembly. FIG. 26H shows the plunger ofthe first assembly being actuated to deploy the implant from the lumenof the needle of the second assembly.

FIG. 27 Phase 1 study design with implants containing 200 μg axitinibaccording to one embodiment of the invention.

FIG. 28 Proposed phase 2 study design with an implant containing 600 μgaxitinib according to one embodiment of the invention.

DEFINITIONS

The term “implant” as used herein (sometimes also referred to as“depot”) refers to an object that contains an active agent, specificallya tyrosine kinase inhibitor (TKI) such as axitinib, as well as othercompounds as disclosed herein, and that is administered into the humanor animal body, e.g., to the vitreous humor of the eye (also called“vitreous chamber” or “vitreous body”) where it remains for a certainperiod of time while it releases the active agent into the surroundingenvironment. An implant can have any predetermined shape (such asdisclosed herein) before being injected, which shape is maintained to acertain degree upon placing the implant into the desired location,although dimensions of the implant (e.g. length and/or diameter) maychange after administration due to hydration as further disclosedherein. In other words, what is injected into the eye is not a solutionor suspension, but an already shaped, coherent object. The implant hasthus been completely formed as disclosed herein prior to beingadministered, and in the embodiments of the present invention is notcreated in situ at the desired location in the eye (as would generallyalso be possible with suitable formulations). Once administered, overthe course of time the implant is biodegraded (as disclosed below) inphysiological environment, may thereby change its shape while itdecreases in size until it has been completely dissolved/resorbed.Herein, the term “implant” is used to refer both to an implant in ahydrated (also referred to herein as “wet”) state when it containswater, e.g. after the implant has been hydrated or re-hydrated onceadministered to the eye or otherwise immersed into an aqueousenvironment (such as in vitro), as well as to an implant in its/a dry(dried/dehydrated) state, i.e., after the implant has been produced anddried and just prior to being loaded into a needle, or after having beenloaded into a needle as disclosed herein, or wherein the implant hasbeen manufactured in a dry state without the need for dehydration. Thus,in certain embodiments, an implant in its dry/dried state in the contextof the present invention may contain no more than about 1% by weightwater. The water content of an implant in its dry/dried state may bemeasured e.g. by means of a Karl Fischer coulometric method. Wheneverdimensions of an implant (i.e., length, diameter, or volume) arereported herein in the hydrated state, these dimensions are measuredafter the implant has been immersed in phosphate-buffered saline at 37°C. for 24 hours. Whenever dimensions of an implant are reported hereinin the dry state, these dimensions are measured after the implant hasbeen fully dried (and thus, in certain embodiments, contain no more thanabout 1% by weight water) and the implant is in a state to be loadedinto a needle for subsequent administration. In certain embodiments, theimplant is kept in an inert atmosphere glove box containing below 20 ppmof both oxygen and moisture for at least about 7 days. Details of anembodiment of the dimension measurement are reported in Example 6.1.

The term “ocular” as used in the present invention refers to the eye ingeneral, or any part or portion of the eye (as an “ocular implant”according to the invention can in principle be administered to any partor portion of the eye) or any disease of the eye (as in one aspect thepresent invention generally refers to treating any diseases of the eye(“ocular diseases”), of various origin and nature. The present inventionin certain embodiments is directed to intravitreal injection of anocular implant (in this case the “ocular implant” is thus an“intravitreal implant”), and to the treatment of ocular diseasesaffecting the posterior segment of the eye, as further disclosed below.

The term “patient” herein includes both human and animal patients. Theimplants according to the present invention are therefore suitable forhuman or veterinary medicinal applications. The patients enrolled andtreated in the clinical study reported in Example 6 are referred to as“subjects”. Generally, a “subject” is a (human or animal) individual towhich an implant according to the present invention is administered,such as during a clinical study. A “patient” is a subject in need oftreatment due to a particular physiological or pathological condition.

The term “biodegradable” refers to a material or object (such as theocular implant according to the present invention) which becomesdegraded in vivo, i.e., when placed in the human or animal body. In thecontext of the present invention, as disclosed in detail herein below,the implant comprising the hydrogel within which particles of a TKI suchas particles of axitinib, are dispersed, slowly biodegrades over timeonce deposited within the eye, e.g., within the vitreous humor. Incertain embodiments biodegradation takes place at least in part viaester hydrolysis in the aqueous environment of the vitreous. The implantslowly dissolves until it is fully resorbed and is no longer visible inthe vitreous.

A “hydrogel” is a three-dimensional network of hydrophilic natural orsynthetic polymers (as disclosed herein) that can swell in water andhold an amount of water while maintaining or substantially maintainingits structure, e.g., due to chemical or physical cross-linking ofindividual polymer chains. Due to their high water content, hydrogelsare soft and flexible, which makes them very similar to natural tissue.In the present invention the term “hydrogel” is used to refer both to ahydrogel in the hydrated state when it contains water (e.g. after thehydrogel has been formed in an aqueous solution, or after the hydrogelhas been (re-)hydrated once implanted into the eye or other part of thebody or otherwise immersed into an aqueous environment) and to ahydrogel in its dry (dried/dehydrated) state when it has been dried to alow water content of e.g. not more than 1% by weight. In the presentinvention, wherein an active principle is contained (e.g. dispersed) ina hydrogel, the hydrogel may also be referred to as a “matrix”.

The term “polymer network” describes a structure formed of polymerchains (of the same or different molecular structure and of the same ordifferent molecular weight) that are crosslinked with each other. Thetypes of polymers suitable for the purposes of the present invention aredisclosed herein. The polymer network may also be formed with the aid ofa crosslinking agent as also disclosed herein.

The term “amorphous” refers to a polymer or polymer network or otherchemical substance or entity which does not exhibit crystallinestructures in X-ray or electron scattering experiments.

The term “semi-crystalline” refers to a polymer or polymer network orother chemical substance or entity which possesses some crystallinecharacter, i.e., exhibits some crystalline properties in X-ray orelectron scattering experiments.

The term “crystalline” refers to a polymer or polymer network or otherchemical substance or entity which has crystalline character asevidenced by X-ray or electron scattering experiments.

The term “precursor” herein refers to those molecules or compounds thatare reacted with each other and that are thus connected via crosslinksto form the polymer network and thus the hydrogel matrix. While othermaterials might be present in the hydrogel, such as active agents orbuffers, they are not referred to as “precursors”.

The parts of the precursor molecules that are still present in the finalpolymer network are also called “units” herein. The “units” are thus thebuilding blocks or constituents of the polymer network forming thehydrogel. For example, a polymer network suitable for use in the presentinvention may contain identical or different polyethylene glycol unitsas further disclosed herein.

The molecular weight of a polymer precursor as used for the purposes ofthe present invention and as disclosed herein may be determined byanalytical methods known in the art. The molecular weight ofpolyethylene glycol may for example be determined by any method known inthe art, including gel electrophoresis such as SDS-PAGE (sodium dodecylsulphate-polyacrylamide gel electrophoresis), gel permeationchromatography (GPC), including GPC with dynamic light scattering (DLS),liquid chromatography (LC), as well as mass spectrometry such asmatrix-assisted laser desorption/ionization-time of flight (MALDI-TOF)spectrometry or electrospray ionization (ESI) mass spectrometry. Themolecular weight of a polymer, including a polyethylene glycol precursoras disclosed herein, is an average molecular weight (based on thepolymer's molecular weight distribution), and may therefore be indicatedby means of various average values, including the weight averagemolecular weight (Mw) and the number average molecular weight (Mn). Inthe case of polyethylene glycol precursors as used in the presentinvention, the molecular weight indicated herein is the number averagemolecular weight (Mn).

In certain embodiments of the present invention, the term “fiber” (usedinterchangeably herein with the term “rod”) characterizes an object(i.e., in the present case the implant according to the presentinvention) that in general has an elongated shape. Specific dimensionsof implants of the present invention are disclosed herein. The implantmay have a cylindrical or essentially cylindrical shape, or may have anon-cylindrical shape. The cross-sectional area of the fiber or theimplant may be either round or essentially round, but may in certainembodiments also be oval or oblong, or may in other embodiments havedifferent geometries, such as cross-shaped, star-shaped or other asdisclosed herein.

The term “release” (and accordingly the terms “released”, “releasing”etc.) as used herein refers to the provision of agents such as an APIfrom an implant of the present invention to the surrounding environment.The surrounding environment may be an in vitro or in vivo environment asdescribed herein. In certain specific embodiments, the surroundingenvironment is the vitreous humor and/or ocular tissue, such as theretina and the choroid. Thus, whenever it is herein stated that theimplant “releases” or “provides for (sustained) release” of a TKI suchas axitinib, this not only refers to the provision of TKI such asaxitinib directly from the implant while the hydrogel has not yet(fully) biodegraded, but also refers to the continued provision of TKIsuch as axitinib to the surrounding environment following fulldegradation of the hydrogel when remaining TKI is still present in thissurrounding environment (e.g. in an agglomerated form as furtherdisclosed herein) for an extended period of time and continues to exertits therapeutic effect. Accordingly, the “treatment period” referred toherein (i.e., the period during which a certain therapeutic effect asdescribed herein is achieved) may extend to a period of time even afterthe implant/the hydrogel has fully biodegraded as further disclosedherein.

The term “sustained release” is defined for the purposes of the presentinvention to refer to products (in the case of the present invention theproducts are implants) which are formulated to make a drug availableover an extended period of time, thereby allowing a reduction in dosingfrequency compared to an immediate release dosage form (such as e.g. asolution of an active principle that is injected into the eye). Otherterms that may be used herein interchangeably with “sustained release”are “extended release” or “controlled release”. “Sustained release” thuscharacterizes the release of an API, specifically, the TKI, such asaxitinib, that is contained in an implant according to the presentinvention. The term “sustained release” per se is not associated with orlimited to a particular rate of (in vitro or in vivo) release, althoughin certain embodiments of the invention an implant may be characterizedby a certain average rate of (in vitro or in vivo) release or a certainrelease profile as disclosed herein. As an implant of the presentinvention (whether explicitly referred to herein as a “sustainedrelease” implant or simply as an “implant”) provides for sustainedrelease of the API, an implant of the present invention may thereforealso be referred to as a “depot”.

Whenever it is stated herein that a certain administration or injectionis performed “concurrently with” or “simultaneously to” or “at the sametime as” an administration or injection of an implant according to thepresent invention, this means that the respective injection of eithertwo or more implants or the injection of one or more implant(s) togetherwith the injection of a suspension or solution e.g. of an anti-VEGFagent as disclosed herein is normally performed immediately one afterthe other, i.e., without any significant delay. For example, if a totaldose of about 400 μg axitinib is to be administered to one eye and thattotal dose is comprised in two implants according to the invention, eachcontaining about 200 μg of axitinib, these two implants are normallyinjected into the vitreous chamber immediately one after the otherwithin the same treatment session, of course by respecting allprecautions for a safe and precise injection at the desired site, butwithout any unnecessary delay. The same applies to the administration ofone or more implant(s) according to the present invention concurrentlywith/simultaneously to/at the same time with the administration of anadditional anti-VEGF agent as described herein. In case the additionalanti-VEGF agent is administered by an intravitreal injection of asuspension or solution containing the anti-VEGF agent, this injection isalso normally intended to take place immediately (as disclosed above)before or after the intravitreal injection of the one or more implant(s)according to the present invention, i.e., ideally during one treatmentsession.

However, under specific circumstances, e.g. in case complications duringthe administration of the first implant are experienced and/or thephysician carrying out the injection concludes that a second injectionduring the same session on the same day, or within the following days,may not be advisable, the second implant may also be administered e.g.one or two weeks after the first implant. Since, as will be disclosed inmore detail herein, the implants may persist in the vitreous of a humaneye for a duration of an extended period of time, such as for about 9 toabout 12 months, the administration of two implants e.g. one or twoweeks apart is still regarded as “concurrently” in the context of thepresent invention. Similar considerations apply for the “concurrent”administration of an implant according to the present invention and ananti-VEGF agent. Thus, an anti-VEGF agent can be administeredconcurrently, i.e., at or around the same time as described herein, withthe intravitreal administration of an implant of the present invention.

In certain other embodiments, however, an anti-VEGF agent can also beadministered in combination with an intravitreal implant of the presentinvention such that the anti-VEGF agent is administered later, such as 1month or 2 months or 3 months after the intravitreal injection of animplant according to the present invention.

The term “rescue medication” generally refers to a medication that maybe administered to a patient under pre-defined conditions (e.g. during astudy in case a patient does not sufficiently respond to investigationaltreatment), or to manage an emergency situation. The conditions foradministering rescue medication in the clinical study disclosed inExample 6 herein are indicated under the sub-heading “Rescue medication”in the description of Example 6 (for % rescue medication administration,see in particular Table 27). In certain embodiments of the presentinvention, “rescue medication” refers to one dose of an anti-VEGF agentas disclosed herein, administered as an intravitreal injection of asolution or suspension of the anti-VEGF agent. In certain specificembodiments, the rescue medication is one dose (2 mg) afliberceptadministered by means of intravitreal injection.

As used herein, the term “about” in connection with a measured quantity,refers to the normal variations in that measured quantity, as expectedby one of ordinary skill in the art in making the measurement andexercising a level of care commensurate with the objective ofmeasurement and the precision of the measuring equipment.

The term “at least about” in connection with a measured quantity refersto the normal variations in the measured quantity, as expected by one ofordinary skill in the art in making the measurement and exercising alevel of care commensurate with the objective of measurement andprecisions of the measuring equipment and any quantities higher thanthat.

The term “average” as used herein refers to a central or typical valuein a set of data(points), which is calculated by dividing the sum of thedata(points) in the set by their number (i.e., the mean value of a setof data).

As used herein, the singular forms “a,” “an”, and “the” include pluralreferences unless the context clearly indicates otherwise.

The term “and/or” as used in a phrase such as “A and/or B” herein isintended to include both “A and B” and “A or B”.

Open terms such as “include,” “including,” “contain,” “containing” andthe like as used herein mean “comprising” and are intended to refer toopen-ended lists or enumerations of elements, method steps, or the likeand are thus not intended to be limited to the recited elements, methodsteps or the like but are intended to also include additional, unrecitedelements, method steps or the like.

The term “up to” when used herein together with a certain value ornumber is meant to include the respective value or number.

The terms “from A to B”, “of from A to B”, and “of A to B” are usedinterchangeably herein and all refer to a range from A to B, includingthe upper and lower limits A and B.

The terms “API”, “active (pharmaceutical) ingredient”, “active(pharmaceutical) agent”, “active (pharmaceutical) principle”, “(active)therapeutic agent”, “active”, and “drug” are used interchangeably hereinand refer to the substance used in a finished pharmaceutical product(FPP) as well as the substance used in the preparation of such afinished pharmaceutical product, intended to furnish pharmacologicalactivity or to otherwise have direct effect in the diagnosis, cure,mitigation, treatment or prevention of a disease, or to have directeffect in restoring, correcting or modifying physiological functions ina patient.

In certain embodiments, the TKI used according to the present inventionis axitinib. Axitinib is the active ingredient in INLYTA® (Pfizer, NY),indicated for the treatment of advanced renal cell carcinoma. It is asmall molecule (386.47 Daltons) synthetic tyrosine kinase inhibitor. Theprimary mechanism of action is inhibition of angiogenesis (the formationof new blood vessels) by inhibition of receptor tyrosine kinases,primarily: VEGFR-1, VEGFR-2, VEGFR-3, PDGFR-β and c-Kit (Keating.Axitinib: a review in advanced renal cell carcinoma. 2015, Drugs,75(16):1903-13; Kernt et al., Inhibitory activity of ranibizumab,sorafenib, and pazopanib on light-induced overexpression ofplatelet-derived growth factor and vascular endothelial growth factor Aand the vascular endothelial growth factor receptors 1 and 2 andneuropilin 1 and 2. 2012, Retina, 32(8):1652-63), which are involved inpathologic angiogenesis, tumor growth, and cancer progression. Axitinibis therefore a multi-target inhibitor that inhibits both VEGF and PDGFpathways.

The molecular formula of axitinib is C₂₂H₁₈N₄₀S, and its IUPAC name isN-methyl-2-[3-((E)-2-pyridin-2-yl-vinyl)-1H-indazol-6-ylsulfanyl]-benzamide.It has the following chemical structure:

The solubility of axitinib in biorelevant media (PBS, pH 7.2 at 37° C.)has been determined to be low, approximately 0.4 to 0.5 μg/mL. Itspartition coefficient (n-octanol/water) is 4.2 (log P; cf. DrugBankentry “axitinib”).

For the purposes of the present invention, active agents (includingaxitinib) in all their possible forms, including any active agentpolymorphs or any pharmaceutically acceptable salts, anhydrates,hydrates, other solvates or derivatives of active agents, can be used.Whenever in this description or in the claims an active agent isreferred to by name, e.g., “axitinib”, even if not explicitly stated, italso refers to any such polymorphs, pharmaceutically acceptable salts,anhydrates, solvates (including hydrates) or derivatives of the activeagent.

The term “polymorph” as used herein refers to any crystalline form of anactive agent such as axitinib. Frequently, active agents that are solidat room temperature exist in a variety of different crystalline forms,i.e, polymorphs, with one polymorph being the thermodynamically moststable at a given temperature and pressure.

With respect to axitinib, suitable solid forms and polymorphs ofaxitinib including anhydrous forms and solvates are for exampledisclosed in A. M. Campeta et al., Journal of Pharmaceutical Sciences,Vol. 99, No. 9, September 2010, 3874-3886. All axitinib polymorphs(whether anhydrous forms or solvates) can be used for preparing implantsaccording to certain embodiments of the present invention, including themost thermodynamically stable polymorph of axitinib referred to as XLIin e.g. U.S. Pat. No. 8,791,140 B2. XLI is an anhydrous crystalline formof axitinib. In certain embodiments of the invention, the axitinib usedfor preparing the implants according to the present invention is theanhydrous crystalline form XLI. In certain other embodiments,crystalline anhydrous forms of axitinib that are suitable for use in thepresent invention include (but are not limited to) polymorphs I, IV, VI,and XXV. In addition to the anhydrous forms, there exist numeroussolvates of axitinib with various solvents, as also described in thecited art, which also can all be used for preparing implants accordingto the present invention. All the above-mentioned forms arewell-characterized and described in the art, such as in the paper byCampeta et al. cited above, or in the patent literature, including, butnot limited to U.S. Pat. No. 8,791,140 B2, US 2006/0094763, and WO2016/178150 A1. Any of the axitinib polymorphic forms known anddisclosed in the art, specifically (but not limited to) the referencescited herein, may be used in the present invention.

In certain specific embodiments, the axitinib used for preparing theimplants according to the present invention and/or present in theimplants according to the present invention is characterized by an XRDpattern comprising at least five characteristic 2θ peaks selected from8.3, 9.3, 13.7, 15.6, 16.1, 16.5, 17.6, 18.6, 21.0, 22.6, 23.1, 23.4,24.1, and 26.0, each value+0.2 2θ°. Particularly, axitinib used forpreparing the implants according to the present invention and/or presentin the implants according to the present invention is characterized byan XRD pattern comprising at least five characteristic 20° peaksselected from 8.3, 9.3, 15.6, 16.5, 17.6, 21.0, 24.1 and 26.0, eachvalue±0.2 2θ°, and/or ¹³C NMR in DMSO solvent comprising chemical shiftsat 26.1, 114.7, 154.8 and 167.8, each shift±0.2 ppm, and/or ¹³C solidstate NMR comprising chemical shifts at 171.1, 153.2, 142.6, 139.5,131.2, 128.1 and 126.3, each shift±0.2 ppm, and/or characterized by aDSC isotherm comprising two endothermic peaks ranging between 213° C. to217° C. (Peak 1) and 219° C. to 224° C. (Peak 2). In one specificembodiment, the non-solvated crystalline form SAB-I of axitinibdisclosed in WO 2016/178150 may be used for preparing the implantsaccording to the present invention.

Axitinib inhibits VEGF signaling and it also inhibits PDGF signaling. Inaddition to inhibiting VEGF/PDGF, it inhibits c-kit, a survival factorfor developing blood vessels with a clearance half-life (t_(1/2)) of afew hours (Rugo et al., Phase I trial of the oral antiangiogenesis agentAG-013736 in patients with advanced solid tumors. 2005, J clin Oncol.,23(24):5474-83), whereas ranibizumab and aflibercept each have t_(1/2)of several days in the human eye. Longer t_(1/2) of these large moleculeantibodies enable them to maintain efficacious tissue concentrations forweeks, whereas small molecules are cleared more quickly. However, due tothe low solubility of axitinib and its inclusion in the hydrogel implantof the present invention which remains in the vitreous humor (VH) for anextended period of time, such as for months, therapeutically effectiveamounts of axitinib are delivered over the period the implant persistsin the VH. Therefore, intravitreal sustained delivery of axitinibprovides a multi-target inhibitor that can in principle inhibit bothVEGF and PDGF pathways without the need of combination therapies andwithout the need for frequent intravitreal injections.

As used herein, the term “therapeutically effective” refers to theamount of drug or active agent needed to produce a certain desiredtherapeutic result after administration. For example, in the context ofthe present invention, one desired therapeutic result would be thereduction of the central subfield thickness (CSFT) as measured byoptical coherence tomography in a patient suffering from neovascular AMDas patients suffering from neovascular AMD have elevated CSFT. A“therapeutically effective” amount of an active agent in the context ofthe present invention may also be a multiple of the IC₅₀ this activeagent provides against a particular substrate, such as 50 or more timesthe IC₅₀. For example, IC₅₀ values of the TKI axitinib againstangiogenesis-related RTKs are presented in Table 12.

The abbreviation “PBS” when used herein means phosphate-buffered saline.

The abbreviation “PEG” when used herein means polyethylene glycol.

DETAILED DESCRIPTION I. The Implant The Active Principle:

One aspect of the present invention is a sustained release biodegradableocular implant comprising a hydrogel and at least about 150 μg of atyrosine kinase inhibitor (TKI), wherein TKI particles are dispersedwithin the hydrogel. In one embodiment, the present invention provides asustained release biodegradable ocular implant comprising a hydrogel andat least about 150 μg of a tyrosine kinase inhibitor (TKI), wherein TKIparticles are dispersed within the hydrogel, and wherein the implant inits dry state has a length of less than about 17 mm.

The active principle contained in an implant of this aspect of theinvention is a TKI. Examples for suitable TKIs are axitinib, sorafenib,sunitinib, nintedanib, pazopanib, regorafenib, cabozantinib, andvandetanib. In particular embodiments, the TKI used in this and otheraspects of the present invention is axitinib. Details on axitinib, itschemical structure, polymorphs, solvates, salts etc. and its propertiessuch as solubility are provided above in the definitions section.

All features (individually or any combinations of features) disclosedherein with respect to an implant according to the present invention maybe used to characterize the sustained release biodegradable ocularimplant comprising a hydrogel and at least about 150 μg of a tyrosinekinase inhibitor (TKI), wherein TKI particles are dispersed within thehydrogel, and wherein the implant in its dry state has a length of lessthan about 17 mm.

In particular embodiments, the implant of the invention is anintravitreal implant, i.e., is administered to the vitreous humor (alsoreferred to herein as “administered intravitreally”).

The TKI, such as axitinib, is contained in the implant of the inventionin a range of doses as disclosed herein of at least 150 μg, such as fromabout 150 μg to about 1800 μg, from about 150 μg to about 1200 μg, orfrom about 200 μg to about 800 μg. Any TKI, such as axitinib, amountwithin these ranges may be used, such as about 150 μg, about 200 μg,about 300 μg, about 400 μg, about 500 μg, about 600 μg, about 700 μg,about 800 μg, about 900 μg, about 1000 μg, about 1100 μg or about 1200μg. In alternative embodiments, the dose of TKI contained in an implantof the invention, such as axitinib, may also be up to about 1800 μg,such as about 1300 μg, about 1400 μg, about 1500 μg, about 1600 μg,about 1700 μg, or about 1800 μg. In further alternative embodiments, thedose of TKI contained in an implant of the invention, such as axitinib,may be even higher than about 1800 μg or higher than about 2000 μg, suchas up to about 3000 μg, up to about 6000 μg, or up to about 10000 μg.All mentioned values also include a variance of +25% and −20%, or avariance of +/−10%.

In certain particular embodiments, the doses of axitinib contained in animplant of the invention are:

-   -   a range from about 160 μg to about 250 μg, or from about 180 μg        to about 220 μg, or about 200 μg (i.e., including a variance of        +25% and −20%, or a variance of +/−10% of 200 μg)    -   a range from about 320 μg to about 500 μg, or from about 360 μg        to about 440 μg, or about 400 μg (i.e., including a variance of        +25% and −20%, or a variance of +/−10% of 400 μg)    -   a range from about 375 μg to about 600 μg, or from about 450 μg        to about 550 μg, or about 500 μg (i.e., including a variance of        +25% and −20%, or a variance of +/−10% of 500 μg)    -   a range from about 480 μg to about 750 μg, or from about 540 μg        to about 660 μg, or about 600 μg (i.e., including a variance of        +25% and −20%, or a variance of +/−10% of 600 μg)    -   a range from about 640 μg to about 1000 μg, or from about 720 μg        to about 880 μg, or about 800 μg (i.e., including a variance of        +25% and −20%, or a variance of +/−10% of 800 μg)    -   a range from about 800 μg to about 1250 μg, or from about 900 μg        to about 1100 μg, or about 1000 μg (i.e., including a variance        of +25% and −20%, or a variance of +/−10% of 1000 μg)    -   a range from about 960 μg to about 1500 μg, or from about 1080        μg to about 1320 μg, or about 1200 μg (i.e., including a        variance of +25% and −20%, or a variance of +/−10% of 1200 μg)    -   a range from about 1440 μg to about 2250 μg, or from about 1620        μg to about 1980 μg, or about 1800 μg (i.e., including a        variance of +25% and −20%, or a variance of +/−10% of 1800 μg).

In one preferred embodiment, the dose of axitinib contained in oneimplant of the invention is from about 480 μg to about 750 μg, or fromabout 540 μg to about 660 μg, or in particular embodiments is about 600μg.

The disclosed amounts of TKI, such as axitinib, including the mentionedvariances, refer to both the final content of the active principle inthe implant, as well as to the amount of active principle used as astarting component per implant when manufacturing the implant.

As will be disclosed in more detail herein below and as will becomeapparent from the Examples section, in certain embodiments of theinvention the total dose of the TKI, such as axitinib, to beadministered to a patient, may be contained in two, three or moreimplants administered concurrently. For example, a dose of about 400 μgof TKI, such as axitinib, may be administered in one implant containingabout 400 μg axitinib, or in two implants e.g. each containing about 200μg axitinib and so on. Of course, one may not only combine two or moreidentical implants (or implants containing the identical dose), but alsotwo or more different implants (or implants containing different doses)in order to arrive at a desired total dose. In a particular embodiment,a total axitinib dose of from about 480 μg to about 750 μg, or fromabout 540 μg to about 660 μg, or of about 600 μg, is contained in oneimplant and only one such implant is administered to a patient in needof such treatment in accordance with the invention. In anotherembodiment, a total dose of higher than about 600 μg, such as from about800 μg to about 1250 μg, or from about 900 μg to about 1100 μg, or ofabout 1000 μg, or a total dose from about 960 μg to about 1500 μg, orfrom about 1080 μg to about 1320 μg, or of about 1200 μg, or a totaldose from about 1440 μg to about 2250 μg, or from about 1620 μg to about1980 μg, or of about 1800 μg is contained in one implant and only onesuch implant is administered to a patient in need of such treatment inaccordance with the invention. In other embodiments, the total doseadministered to a patient in accordance with the present invention maybe contained in two or more implants (containing the same or differentamounts of API) administered concurrently.

The TKI, such as axitinib, is contained in the implant of the inventionand is dispersed or distributed in the hydrogel that is comprised of apolymer network. In certain embodiments, the particles are homogeneouslyor essentially homogeneously dispersed in the hydrogel. The hydrogel mayprevent the particles from agglomerating and may provide a matrix forthe particles which holds them in the desired location in the eye whileslowly releasing drug.

In certain embodiments of the invention, the TKI particles such as theaxitinib particles may be microencapsulated. The term “microcapsule”(also referred to as “microparticle”) is sometimes defined as a roughlyspherical particle with a size varying between e.g. about 50 nm to about2 mm. Microcapsules have at least one discrete domain (or core) ofactive agent encapsulated in a surrounding material, sometimes alsoreferred to as a shell. One suitable agent (without limiting the presentdisclosure to this) for microencapsulating the TKI, such as theaxitinib, for the purposes of the present invention, is poly(lactic-co-glycolic acid).

In other embodiments, the TKI particles such as the axitinib particlesare not microencapsulated and are thus dispersed in the hydrogel andthus in the implant of the invention as they are, i.e., without beingadmixed to or adjoined with or microencapsulated by another materialsuch as (but not limited to) poly (lactic-co-glycolic acid).

In one embodiment, the TKI particles, such as the axitinib particles,may be micronized particles. In another embodiment, the TKI particles,such as the axitinib particles, may not be micronized. Micronizationrefers to the process of reducing the average diameter of particles of asolid material. Particles with reduced diameters may have inter aliahigher dissolution and erosion rates, which increases thebioavailability of active pharmaceutical ingredients and may have incertain embodiments a positive impact on release kinetics. Furthermore,micronized particles may have a reduced tendency to agglomerate duringmanufacturing operations (see also FIG. 24). In the composite materialsfield, particle size is known to affect the mechanical properties whencombined with a matrix, with smaller particles providing superiorreinforcement for a given mass fraction. Thus, a hydrogel matrix filledwith micronized TKI particles may have improved mechanical properties(e.g. brittleness, strain to failure, etc.) compared to a similar massfraction of larger TKI particles. Such properties are important inmanufacturing, during implantation, and during degradation of theimplant. Micronization may also promote a more homogeneous distributionof the active ingredient in the chosen dosage form or matrix. Theparticle size distribution can be measured by methods known in the art,including sieving, laser diffraction or dynamic light scattering. Incertain embodiments of the invention the TKI, such as the axitinib,particles used in preparing the implants of the present invention mayhave a d90 of less than about 100 μm and/or a d50 of less than about 50μm, or a d90 of less than about 75 μm and/or a d50 or less than about 20μm as determined by laser diffraction. In specific embodiments, the d90of the TKI, such as the axitinib, may be less than about 30 μm, lessthan about 20 μm as determined by laser diffraction. In very particularembodiments, the d90 of the TKI, such as axitinib, is less than about 10μm as determined by laser diffraction. In these or other embodiments,the d50 of the TKI, such as axitinib, particles used in preparing theimplants of the present invention may be less than about 5 μm asdetermined by laser diffraction. In these or other embodiments, the d10of the TKI, such as the axitinib, particles used in the presentinvention may be less than about 3 μm as determined by laserdiffraction. In certain embodiments, the d100 of the TKI, such as theaxitinib, particles used in the preparation of the implants of thepresent invention may be less than about 20 μm as determined by laserdiffraction. The “d90” (also referred to as “D90” herein) value meansthat 90 volume-% of all particles within the measured bulk material(which has a certain particle size distribution) have a particle sizebelow the indicated value. For example, a d90 particle size of less thanabout 10 μm means that 90 volume-% of the particles in the measured bulkmaterial have a particle size below about 10 μm. Correspondingdefinitions apply to other “d” values, such as the “d10”, “d50” or the“d100” values (also referred to herein as the “D10”, “D50” and “D100”values, respectively). In certain other embodiments also TKI, such asaxitinib, particles with diameters above this specification may be used.

Micronized TKI such as axitinib particles may be purchased perspecification from the supplier, or may be prepared e.g. according tothe following exemplary procedure for axitinib (disclosed in WO2016/183296 A1, Example 13): 1800 mL of sterile Water For Injection(WFI) is measured into a 2 L beaker and placed on a stir plate stirringat 600 RPM with a stir bar, creating a large WFI vortex in the center ofthe beaker. One 60 mL BD syringe containing axitinib in ethanol isplaced on a syringe pump which is clamped above the WFI beaker. Ahypodermic needle (21 G, BD) is connected to the syringe and aimeddirectly into the center of the vortex for dispensation of the axitinibsolution. The syringe pump is then run at 7.5 mL/min in order to add theaxitinib solution dropwise to the WFI to precipitate micronizedaxitinib. After micronization, the axitinib is filtered, e.g. through a0.2 μm vacuum filter and rinsed with WFI. After filtration, the axitinibpowder is collected from the filter e.g. by using a spatula and vacuumdried for an extended period of time, such as for about 12 or about 24hours, in order to remove excess solvent. Another exemplary method ofmicronizing axitinib is disclosed in Example 9 of WO 2017/091749. Thedescribed method of micronization is not limiting, and other methods ofmicronizing the active agent such as axitinib may equally be used. Thedisclosed micronization method (or other methods) may also be used forother actives than axitinib.

Another aspect of the present invention is a sustained releasebiodegradable ocular implant comprising a hydrogel and at least about150 μg of a tyrosine kinase inhibitor (TKI), wherein TKI particles aredispersed within the hydrogel, and wherein the implant in its dry statehas a total weight of about 0.2 mg to about 1.5 mg. In certainembodiments, the TKI is axitinib or another TKI as disclosed herein.

In certain embodiments, the total weight (also referred to herein as“total mass”) of an implant according to the present invention in itsdry state may be from about 400 μg to about 1.2 mg. In certain specificembodiments, the total weight of an implant according to the inventionin its dry state may be from about 0.3 mg to about 0.6 mg, such as fromabout 0.4 mg to about 0.5 mg, or may be from about 0.8 mg to about 1.1mg, such as from about 0.9 mg to about 1.0 mg.

All features (individually or any combinations of features) disclosedherein with respect to an implant according to the present invention maybe used to characterize the sustained release biodegradable ocularimplant comprising a hydrogel and at least about 150 μg of a tyrosinekinase inhibitor (TKI), wherein TKI particles are dispersed within thehydrogel, and wherein the implant in its dry state has a total weight ofabout 0.2 mg to about 1.5 mg.

The Polymer Network:

In certain embodiments, the hydrogel may be formed from precursorshaving functional groups that form crosslinks to create a polymernetwork. These crosslinks between polymer strands or arms may bechemical (i.e., may be covalent bonds) and/or physical (such as ionicbonds, hydrophobic association, hydrogen bridges etc.) in nature.

The polymer network may be prepared from precursors, either from onetype of precursor or from two or more types of precursors that areallowed to react. Precursors are chosen in consideration of theproperties that are desired for the resultant hydrogel. There arevarious suitable precursors for use in making the hydrogels. Generally,any pharmaceutically acceptable and crosslinkable polymers forming ahydrogel may be used for the purposes of the present invention. Thehydrogel and thus the components incorporated into it, including thepolymers used for making the polymer network, should be physiologicallysafe such that they do not elicit e.g. an immune response or otheradverse effects. Hydrogels may be formed from natural, synthetic, orbiosynthetic polymers.

Natural polymers may include glycosaminoglycans, polysaccharides (e.g.dextran), polyaminoacids and proteins or mixtures or combinationsthereof.

Synthetic polymers may generally be any polymers that are syntheticallyproduced from a variety of feedstocks by different types ofpolymerization, including free radical polymerization, anionic orcationic polymerization, chain-growth or addition polymerization,condensation polymerization, ring-opening polymerization etc. Thepolymerization may be initiated by certain initiators, by light and/orheat, and may be mediated by catalysts.

Generally, for the purposes of the present invention one or moresynthetic polymers of the group comprising one or more units ofpolyalkylene glycol, such as polyethylene glycol (PEG), polypropyleneglycol, poly(ethylene glycol)-block-poly(propylene glycol) copolymers,or polyethylene oxide, polypropylene oxide, polyvinyl alcohol, poly(vinylpyrrolidinone), polylactic acid, polylactic-co-glycolic acid,random or block copolymers or combinations/mixtures of any of these canbe used, while this list is not intended to be limiting.

To form covalently crosslinked polymer networks, the precursors may becovalently crosslinked with each other. In certain embodiments,precursors with at least two reactive centers (for example, in freeradical polymerization) can serve as crosslinkers since each reactivegroup can participate in the formation of a different growing polymerchain.

The precursors may have biologically inert and hydrophilic portions,e.g., a core. In the case of a branched polymer, a core refers to acontiguous portion of a molecule joined to arms that extend from thecore, where the arms carry a functional group, which is often at theterminus of the arm or branch. Multi-armed PEG precursors are examplesof such precursors and are further disclosed herein below.

Thus a hydrogel for use in the present invention can be made e.g. fromone multi-armed precursor with a first (set of) functional group(s) andanother multi-armed precursor having a second (set of) functionalgroup(s). By way of example, a multi-armed precursor may havehydrophilic arms, e.g., polyethylene glycol units, terminated withprimary amines (nucleophile), or may have activated ester end groups(electrophile). The polymer network according to the present inventionmay contain identical or different polymer units crosslinked with eachother.

Certain functional groups can be made more reactive by using anactivating group. Such activating groups include (but are not limitedto) carbonyldiimidazole, sulfonyl chloride, aryl halides,sulfosuccinimidyl esters, N-hydroxysuccinimidyl ester, succinimidylester, epoxide, aldehyde, maleimides, imidoesters, acrylates and thelike. The N-hydroxysuccinimide esters (NHS) are useful groups forcrosslinking of nucleophilic polymers, e.g., primary amine-terminated orthiol-terminated polyethylene glycols. An NHS-amine crosslinkingreaction may be carried out in aqueous solution and in the presence ofbuffers, e.g., phosphate buffer (pH 5.0-7.5), triethanolamine buffer (pH7.5-9.0), borate buffer (pH 9.0-12), or sodium bicarbonate buffer (pH9.0-10.0).

In certain embodiments, each precursor may comprise only nucleophilic oronly electrophilic functional groups, so long as both nucleophilic andelectrophilic precursors are used in the crosslinking reaction. Thus,for example, if a crosslinker has only nucleophilic functional groupssuch as amines, the precursor polymer may have electrophilic functionalgroups such as N-hydroxysuccinimides. On the other hand, if acrosslinker has electrophilic functional groups such assulfosuccinimides, then the functional polymer may have nucleophilicfunctional groups such as amines or thiols. Thus, functional polymerssuch as proteins, poly (allyl amine), or amine-terminated di- ormultifunctional poly(ethylene glycol) can be also used to prepare thepolymer network of the present invention.

In one embodiment a first reactive precursor has about 2 to about 16nucleophilic functional groups each (termed functionality), and a secondreactive precursor allowed to react with the first reactive precursor toform the polymer network has about 2 to about 16 electrophilicfunctional groups each. Reactive precursors having a number of reactive(nucleophilic or electrophilic) groups as a multiple of 4, thus forexample 4, 8 and 16 reactive groups, are particularly suitable for thepresent invention. Any number of functional groups, such as includingany of 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or 16 groups, ispossible for precursors to be used in accordance with the presentinvention, while ensuring that the functionality is sufficient to forman adequately crosslinked network.

PEG Hydrogels:

In a certain embodiments of the present invention, the polymer networkforming the hydrogel contains polyethylene glycol (PEG) units. PEGs areknown in the art to form hydrogels when crosslinked, and these PEGhydrogels are suitable for pharmaceutical applications e.g. as matrixfor drugs intended to be administered to all parts of the human oranimal body.

The polymer network of the hydrogel implants of the present inventionmay comprise one or more multi-arm PEG units having from 2 to 10 arms,or 4 to 8 arms, or 4, 5, 6, 7 or 8 arms. The PEG units may have adifferent or the same number of arms. In certain embodiments, the PEGunits used in the hydrogel of the present invention have 4 and/or 8arms. In certain particular embodiments, a combination of 4- and 8-armPEG units is utilized.

The number of arms of the PEG used contributes to controlling theflexibility or softness of the resulting hydrogel. For example,hydrogels formed by crosslinking 4-arm PEGs are generally softer andmore flexible than those formed from 8-arm PEGs of the same molecularweight. In particular, if stretching the hydrogel prior to or afterdrying as disclosed herein below in the section relating to themanufacture of the implant is desired, a more flexible hydrogel may beused, such as a 4-arm PEG, optionally in combination with anothermulti-arm PEG, such as an 8-arm PEG as disclosed above.

In certain embodiments of the present invention, polyethylene glycolunits used as precursors have an average molecular weight in the rangefrom about 2,000 to about 100,000 Daltons, or in a range from about10,000 to about 60,000 Daltons, or in a range from about 15,000 to about50,000 Daltons. In certain particular embodiments the polyethyleneglycol units have an average molecular weight in a range from about10,000 to about 40,000 Daltons, or of about 20,000 Daltons. PEGprecursors of the same average molecular weight may be used, or PEGprecursors of different average molecular weight may be combined witheach other. The average molecular weight of the PEG precursors used inthe present invention is given as the number average molecular weight(Mn), which, in certain embodiments, may be determined by MALDI.

In a 4-arm PEG, each of the arms may have an average arm length (ormolecular weight) of the total molecular weight of the PEG divided by 4.A 4a20kPEG precursor, which is one precursor that can be utilized in thepresent invention thus has 4 arms with an average molecular weight ofabout 5,000 Daltons each. An 8a20k PEG precursor, which may be used inaddition to the 4a20kPEG precursor in the present invention, thus has 8arms each having an average molecular weight of 2,500 Daltons. Longerarms may provide increased flexibility as compared to shorter arms. PEGswith longer arms may swell more as compared to PEGs with shorter arms. APEG with a lower number of arms also may swell more and may be moreflexible than a PEG with a higher number of arms. In certain particularembodiments, combinations of PEG precursors with different numbers ofarms, such as a combination of a 4-arm PEG precursor and an 8-armprecursor, may be utilized in the present invention. In addition, longerPEG arms have higher melting temperatures when dry, which may providemore dimensional stability during storage. For example, an 8-arm PEGwith a molecular weight of 15,000 Dalton crosslinked with trilysine maynot be able to maintain a stretched configuration at room temperature,whereas a 4-arm 20,000 Dalton PEG crosslinked with an 8-arm 20,000Dalton PEG may be dimensionally stable in a stretched configuration atroom temperature.

When referring to a PEG precursor having a certain average molecularweight, such as a 15kPEG- or a 20kPEG-precursor, the indicated averagemolecular weight (i.e., a Mn of 15,000 or 20,000, respectively) refersto the PEG part of the precursor, before end groups are added (“20k”here means 20,000 Daltons, and “15k” means 15,000 Daltons—the sameabbreviation is used herein for other average molecular weights of PEGprecursors). In certain embodiments, the Mn of the PEG part of theprecursor is determined by MALDI. The degree of substitution with endgroups as disclosed herein may be determined by means of ¹H-NMR afterend group functionalization.

In certain embodiments, electrophilic end groups for use with PEGprecursors for preparing the hydrogels of the present invention areN-hydroxysuccinimidyl (NHS) esters, including but not limited to: “SAZ”referring to a succinimidylazelate end group, “SAP” referring to asuccinimidyladipate end group, “SG” referring to a succinimidylglutarateend group, and “SS” referring to a succinimidylsuccinate end group.

In certain embodiments, nucleophilic end groups for use with PEGprecursors for preparing the hydrogels of the present invention areamine (denoted as “NH₂”) end groups. Thiol (—SH) end groups or othernucleophilic end groups are also possible.

In certain preferred embodiments, 4-arm PEGs with an average molecularweight of about 20,000 Daltons and an electrophilic end group asdisclosed above and 8-arm PEGs also with an average molecular weight ofabout 20,000 Daltons and with a nucleophilic end group as disclosedabove are crosslinked for forming the polymer network and thus thehydrogel according to the present invention.

Reaction of nucleophilic group-containing PEG units and electrophilicgroup-containing PEG units, such as amine end-group containing PEG unitsand activated ester-group containing PEG units, results in a pluralityof PEG units being crosslinked by a hydrolyzable linker having theformula:

wherein m is an integer from 0 to 10, and specifically is 1, 2, 3, 4, 5,6, 7, 8, 9, or 10. In one particular embodiment, m is 6, e.g. in thecase a SAZ-end group-containing PEG is used. For a SAP-end group, mwould be 3, for a SG-end group, m would be 2 and for an SS-end group mwould be 1. All crosslinks within the polymer network may be the same,or may be different.

In certain preferred embodiments, the SAZ end group is utilized in thepresent invention. This end group may provide for increased duration inthe eye, and the implant of certain embodiments of the present inventioncomprising a hydrogel comprising PEG-SAZ units is biodegraded in theeye, such as in the vitreous humor of a human eye, only after anextended period of time, e.g., 9 to 12 months as further disclosedbelow, and may in certain circumstance persist even longer. The SAZgroup is more hydrophobic than e.g. the SAP-, SG- or SS-end groupsbecause of a higher number of carbon atoms in the chain (m being 6, andthe total of carbon atoms between the amide group and the ester groupbeing 7).

In certain preferred embodiments, a 4-arm 20,000 Dalton PEG precursor iscombined with an 8-arm 20,000 Dalton PEG precursor, such as a 4-arm20,000 Dalton PEG precursor having a SAZ group (as defined above)combined with an 8-arm 20,000 Dalton PEG precursor having an amine group(as defined above). These precursors are also abbreviated herein as4a20kPEG-SAZ and 8a20kPEG-NH₂, respectively. The chemical structure of4a20kPEG-SAZ is:

wherein R represents a pentaerythritol core structure. The chemicalstructure of 8a20kPEG-NH₂ (with a hexaglycerol core) is:

In the above formulae, n is determined by the molecular weight of therespective PEG-arm.

In certain embodiments, the molar ratio of the nucleophilic and theelectrophilic end groups reacting with each other is about 1:1, i.e.,one amine group is provided per one SAZ group. In the case of4a20kPEG-SAZ and 8a20kPEG-NH₂ this results in a weight ratio of about2:1, as the 8-arm PEG contains double the amount of end groups as the4-arm PEG. However, an excess of either the electrophilic (e.g. the NHSend groups, such as the SAZ) end groups or of the nucleophilic (e.g. theamine) end groups may be used. In particular, an excess of thenucleophilic, such as the amine-end group containing precursor may beused, i.e., the weight ratio of 4a20kPEG-SAZ and 8a20kPEG-NH₂ may alsobe less than 2:1.

Each and any combination of electrophilic- and nucleophilic-groupcontaining PEG precursors disclosed herein may be used for preparing theimplant according to the present invention. For example, any 4-arm or8-arm PEG-NHS precursor (e.g. having a SAZ, SAP, SG or SS end group) maybe combined with any 4-arm or 8-arm PEG-NH₂ precursor (or any other PEGprecursor having a nucleophilic group). Furthermore, the PEG units ofthe electrophilic- and the nucleophilic group-containing precursors mayhave the same, or may have a different average molecular weight.

Another nucleophilic group-containing crosslinking agent may be usedinstead of a PEG-based crosslinking agent. For example, a low-molecularweight amine linker can be used, such as trilysine (or a trilysine saltor derivative, such as trilysine acetate) or other low-molecular weightmulti-arm amines.

In certain embodiments, the nucleophilic group-containing crosslinkingagent may be bound to or conjugated with a visualization agent. Avisualization agent is an agent that contains a fluorophoric or othervisualization-enabling group. Fluorophores such as fluorescein,rhodamine, coumarin, and cyanine may for example be used asvisualization agents. The visualization agent may be conjugated with thecrosslinking agent e.g. through some of the nucleophilic groups of thecrosslinking agent. Since a sufficient amount of the nucleophilic groupsare necessary for crosslinking, “conjugated” or “conjugation” in generalincludes partial conjugation, meaning that only a part of thenucleophilic groups are used for conjugation with the visualizationagent, such as about 1% to about 20%, or about 5% to about 10%, or about8% of the nucleophilic groups of the crosslinking agent may beconjugated with a visualization agent. In other embodiments, avisualization agent may also be conjugated with the polymer precursor,e.g. through certain reactive (such as electrophilic) groups of thepolymer precursors.

Additional Ingredients:

The implant of the present invention may contain, in addition to thepolymer units forming the polymer network as disclosed above and theactive principle, other additional ingredients. Such additionalingredients are for example salts originating from buffers used duringthe preparation of the hydrogel, such as phosphates, borates,bicarbonates, or other buffer agents such as triethanolamine. In certainembodiments of the present invention sodium phosphate buffers(specifically, mono- and dibasic sodium phosphate) are used.

Optionally, preservatives may be used for the implants of the presentinvention. However, in certain embodiments, the implants of the presentinvention including the implants containing axitinib as active agent,are free of preservatives, such as anti-microbial preservatives(including, but not limited to benzalkonium chloride (BAK),chlorobutanol, sodium perborate, and stabilized oxychloro complex(SOC)), or are substantially free of such preservatives.

If an in situ gelation is preferred in an embodiment of the invention,possible additional ingredient may be other agents used duringmanufacture of the hydrogel, such as (without being limited to)viscosity-influencing agents (such as hyaluronic acid etc.), surfactantsetc.

In certain embodiments, the inserts of the present invention may containa visualization agent. Visualization agents that may be used in thecontext of the invention are all agents that can be conjugated with thecomponents of the hydrogel or can be entrapped within the hydrogel, andthat are visible, or may be made visible when exposed e.g. to light of acertain wavelength, or that are contrast agents. Suitable visualizationagents for use in the present invention are (but are not limited to)e.g. fluoresceins, rhodamines, coumarins, cyanines, europium chelatecomplexes, boron dipyromethenes, benzofrazans, dansyls, bimanes,acridines, triazapentalenes, pyrenes and derivatives thereof. Avisualization agent may be conjugated with either the nucleophilic- orthe electrophilic group-containing precursor of which the polymernetwork is formed, as disclosed above, or the visualization agent may bea separate (non-conjugated) agent that is added during the manufactureof the implant and that is present in the hydrogel.

Formulation:

In certain embodiments, implants according to the present inventioncomprise a TKI, a polymer network made from one or more polymerprecursors as disclosed herein above in the form of a hydrogel, andoptional additional components such as salts etc. remaining in theimplant from the production process (such as phosphate salts used asbuffers etc.). In certain preferred embodiments, the TKI is axitinib.

In certain embodiments, the implants according to the present inventionin their dry state may contain from about 15% to about 80%, such as fromabout 25% to about 75% by weight TKI and from about 15% to about 80%,such as from about 20% to about 60% by weight polymer units, or inparticular embodiments from about 35% to about 65% by weight TKI andfrom about 25% to about 50% by weight polymer units (dry composition).In specific embodiments, the implants according to the present inventionmay contain from about 45% to about 55% by weight TKI and from about 37%to about 47% by weight polymer units (dry composition), with the TKI andthe polymer units being selected from those disclosed herein above. Inother specific embodiments, the implants according to the presentinvention in their dry state may contain from about 55% to about 75% byweight TKI and from about 20% to about 40% by weight polymer units (drycomposition), with the TKI and the polymer units being selected fromthose disclosed herein above. In other specific embodiments, theimplants according to the present invention in their dry state maycontain from about 30% to about 45% by weight TKI and from about 47% toabout 70% by weight polymer units (dry composition), with the TKI andthe polymer units being selected from those disclosed herein above.

In one particular embodiment, the implants according to the presentinvention in their dry state may contain from about 25% to about 75% byweight axitinib and from about 20% to about 60% by weight PEG units, orfrom about 35% to about 65% by weight axitinib and from about 25% toabout 50% by weight PEG units, or from about 45% to about 55% by weightaxitinib and from about 37% to about 47% by weight PEG units, or fromabout 48% to about 52% by weight axitinib and from about 40% to about44% by weight PEG units (dry composition). In other particularembodiments, the implants according to the present invention in theirdry state may contain from about 55% to about 75% by weight axitinib andfrom about 20% to about 40% by weight PEG units, or from about 60% toabout 75% by weight axitinib and from about 21% to about 31% by weightPEG units (dry composition).

In one further particular embodiment, on a dry weight basis the axitinibto PEG ratio in an implant according to the invention may beapproximately 50% by weight or more axitinib to approximately 40% byweight or less PEG, the balance being phosphate salt. Alternatively, ona dry weight basis the axitinib to PEG ratio in an implant according tothe invention may be from about 1:1 to about 3:1.

In certain embodiments, the balance of the implant in its dried state(i.e., the remainder of the formulation when TKI, such as axitinib, andpolymer hydrogel, such as PEG hydrogel, have already been taken accountof) may be salts remaining from buffer solutions as disclosed above. Incertain embodiments, such salts are phosphate, borate or (bi) carbonatesalts. In one embodiment the buffer salt is sodium phosphate (mono-and/or dibasic).

The amounts of the TKI and the polymer(s) may be varied, and otheramounts of the TKI and the polymer hydrogel may be used to prepareimplants according to the invention.

In certain embodiments, the maximum amount of drug within theformulation is about two times the amount of the polymer (e.g., PEG)units, but may be higher in certain cases, but it is desired that themixture comprising, e.g., the precursors, buffers and drug (in the statebefore the hydrogel has gelled completely) can be uniformly cast into amold or tubing.

In one embodiment of the invention, the hydrogel after being formed andprior to being dried, i.e., in a wet state, may comprise about 3% toabout 20% polyethylene glycol representing the polyethylene glycolweight divided by the fluid weight×100. In one embodiment, the hydrogelin a wet state comprises about 5% to about 15%, such as about 7.5% toabout 15%, or about 5% to about 10% polyethylene glycol representing thepolyethylene glycol weight divided by the fluid weight×100.

In one embodiment of the invention, the wet hydrogel composition (i.e.,after the hydrogel composition has been formed, i.e., all componentsforming the hydrogel have been admixed) comprises from about 5% to about50% by weight active principle, such as axitinib, and from about 5% toabout 50% or from about 5% to about 30% by weight PEG units.

In certain embodiments, a solids content of about 10% to about 50%, orof about 25% to about 50% (w/v) (wherein “solids” means the combinedweight of polymer precursor(s), salts and the drug insolution/suspension) may be utilized in the wet composition when formingthe hydrogel for the implants according to the present invention. Thus,in certain embodiments, the total solids content of the wet hydrogelcomposition to be cast into a mold or tubing in order to shape thehydrogel may be no more than about 60%, or no more than about 50%, or nomore than about 40%, such as equal to or lower than about 35% (w/v). Thecontent of TKI, such as axitinib, may be no more than about 40%, or nomore than about 30%, such as equal to or lower than about 25% (w/v) ofthe wet composition. The solids content may influence the viscosity andthus may also influence the castability of the wet hydrogel composition.

In certain embodiments, the water content of the hydrogel implant in itsdry (dehydrated/dried) state, e.g. prior to being loaded into a needle,or when loaded in a needle, may be very low, such as not more than 1% byweight of water. The water content may in certain embodiments also belower than that, possibly not more than 0.25% by weight or even not morethan 0.1% by weight. In the present invention the term “implant” is usedto refer both to an implant in a hydrated state when it contains water(e.g. after the implant has been (re-)hydrated once administered to theeye or otherwise immersed into an aqueous environment) as well as to animplant in its dry (dried/dehydrated) state, e.g., when it has beendried to a low water content of e.g. not more than about 1% by weight orwhen the preparation results in such a low water content implant withoutthe necessity of a drying step. In certain embodiments, an implant inits dry state is an implant that after production is kept under inertnitrogen atmosphere (containing less than 20 ppm of both oxygen andmoisture) in a glove box for at least about 7 days prior to being loadedinto a needle. The water content of an implant may be e.g. measuredusing a Karl Fischer coulometric method.

In certain embodiments, the total weight (also referred to herein as“total mass”) of an implant according to the present invention in itsdry state may be from about 200 μg (i.e., 0.2 mg) to about 1.5 mg, orfrom about 400 μg to about 1.2 mg. In certain specific embodiments, thetotal weight of an implant according to the invention in its dry statemay be from about 0.3 mg to about 0.6 mg, such as from about 0.4 mg toabout 0.5 mg, e.g. in case the implant contains axitinib in an amount offrom about 160 μg to about 250 μg. In certain other specificembodiments, the total mass of an implant according to the invention inits dry state may be from about 0.75 mg to about 1.25 mg, or from about0.8 mg to about 1.1 mg, or from about 0.9 mg to about 1.0 mg, e.g. incase the implant contains axitinib in an amount of from about 480 μg toabout 750 μg.

In certain embodiments, an implant according to the present invention inits dry state may contain from about 200 μg to about 1000 μg TKI, suchas axitinib, per mm³ (i.e., per 1 mm³ volume of the dry implant). Incertain specific embodiments, an implant according to the presentinvention in its dry state may contain from about 200 μg to about 300 μgaxitinib per mm³, e.g. in case the implant contains axitinib in anamount of from about 160 μg to about 250 μg. In certain other specificembodiments, an implant according to the present invention in its drystate may contain from about 500 μg to about 800 μg axitinib per mm³,e.g. in case the implant contains axitinib in an amount of from about480 μg to about 750 μg.

The implants of the present invention may thus have different densities.The densities of the final implants (i.e., in their dry state) may becontrolled and determined by various factors, including but not limitedto the concentration of the ingredients in the wet composition whenforming the hydrogel, and certain conditions during manufacturing of theimplant. For example, the density of the final implant in certainembodiments can be increased by means of sonication or degassing, e.g.using vacuum, at certain points during the manufacturing process.

In certain embodiments, implants according to the invention contain atherapeutically effective amount of TKI such as axitinib for releaseover an extended period of time, but are nevertheless relatively smallin length and/or diameter. This is advantageous both in terms of ease ofadministration (injection) as well as in terms of reducing possibledamage to ocular tissue and reducing a possible impact of the patient'svision while the implant is in place. The implants of the presentinvention combine the benefits of a suitably high dose of the TKI (i.e.,a therapeutically effective dose adjusted to a particular patient'sneed) with a relatively small implant size.

Exemplary implants according to the invention are disclosed in theExamples section, in Tables 1, 6, 21.1, 21.2, and 29 (includingprophetic examples of implants according to the invention containing ahigh amount of TKI which are disclosed in Table 29).

Dimensions of the Implant and Dimensional Change Upon Hydration ThroughStretching:

The dried implant may have different geometries, depending on the methodof manufacture, such as the use of mold or tubing into which the mixturecomprising the hydrogel precursors including the TKI is cast prior tocomplete gelling. The implant according to the present invention is alsoreferred as a “fiber” (which term is used interchangeably herein withthe term “rod”), wherein the fiber is an object that has in general anelongated shape. The implant (or the fiber) may have differentgeometries, with specific dimensions as disclosed herein.

In one embodiment, the implant is cylindrical or has an essentiallycylindrical shape. In this case, the implant has a round or anessentially round cross-section.

In other embodiments of the invention, the implant is non-cylindrical,wherein the implant is optionally elongated in its dry state, whereinthe length of the implant is greater than the width of the implant,wherein the width is the largest cross sectional dimension that issubstantially perpendicular to the length. In certain embodiments, thewidth may be about 0.1 mm to about 0.5 mm. Various geometries of theouter implant shape or its cross-section may be used in the presentinvention. For example, instead of a round diameter fiber (i.e., acylindrical implant), a cross-shaped fiber (i.e., wherein thecross-sectional geometry is cross-like) may be used. Othercross-sectional geometries, such as oval or oblong, rectangular,triangular, star-shaped etc. may generally be used. In certainembodiments, the fiber may also be twisted. In embodiments where theimplant is administered to the eye by means of a needle, the dimensionsof the implant (i.e., its length and diameter) and its cross-sectionalgeometry must be such as to enable loading the implant into the needle,particularly a fine-diameter needle such as a 25-gauge or 27-gaugeneedle as further disclosed herein.

The polymer network, such as the PEG network, of the hydrogel implantaccording to certain embodiments of the present invention may besemi-crystalline in the dry state at or below room temperature, andamorphous in the wet state. Even in the stretched form, the dry implantmay be dimensionally stable at or below room temperature, which may beadvantageous for loading the implant into the needle and for qualitycontrol.

Upon hydration of the implant in the eye (which can be simulated byimmersing the implant into PBS, pH 7.2 at 37° C.) the dimensions of theimplant according to the invention may change: generally, the diameterof the implant may increase, while its length may decrease or at leastmay stay essentially the same. An advantage of this dimensional changeis that, while the implant in its dry state is sufficiently thin to beloaded into a fine diameter needle (such as a 25-, or 27-, or in somecases even a smaller diameter needle, such as a 30-gauge needle) to beinjected into the eye, once it has been placed in eye, e.g., in thevitreous humor, the implant may become shorter to better fit within thelimited, small volume of the eye. The needles used for injection of theimplants of the present invention as disclosed herein, such as the 25-or 27-gauge needles in certain embodiments, are small in diameter (ande.g. may have an inner diameter of about 0.4 mm). As the implant alsomay become softer upon hydration, injuries of any ocular tissue can beprevented or minimized even when the implant comes into contact withsuch tissue. In certain embodiments, the dimensional change is enabledat least in part by the “shape memory” effect introduced into theimplant by means of stretching the implant in the longitudinal directionduring its manufacture (as also disclosed below in the section “Methodof manufacture”). In certain embodiments, the stretching may either beperformed in the dry or in the wet state, i.e., after drying thehydrogel implant, or before drying. It is noted that if no stretching isperformed, and the hydrogel implant is only dried and cut into a desiredlength, the implant may increase in both diameter and length uponhydration. If this is not desired, the hydrogel fiber may be dry or wetstretched.

In pre-formed dried hydrogels, a degree of molecular orientation may beimparted by dry-stretching the material then allowing it to solidify,locking in the molecular orientation. This can be accomplished incertain embodiments by drawing the material (optionally while heatingthe material to a temperature above the melting point of thecrystallizable regions of the material), then allowing thecrystallizable regions to crystallize. Alternatively, in certainembodiments the glass transition temperature of the dried hydrogel canbe used to lock in the molecular orientation for polymers such as PVAthat have a suitable glass transition temperature. Still anotheralternative is to stretch the gel prior to complete drying (alsoreferred to as “wet stretching”) and then drying the material whileunder tension. The molecular orientation provides one mechanism foranisotropic swelling upon introduction into a hydrating medium such asthe vitreous. Upon hydration the implant of certain embodiments willswell only in the radial dimension, while the length will eitherdecrease or be essentially maintained. The term “anisotropic swelling”means swelling preferentially in one direction as opposed to another, asin a cylinder that swells predominantly in diameter, but does notappreciably expand (or does even contract) in the longitudinaldimension.

The degree of dimensional change upon hydration may depend inter alia onthe stretch factor. As an example, stretching at e.g. a stretch factorof about 1.3 (e.g. by means of wet stretching) may have a lesspronounced effect or may not change the length during hydration to alarge extent. In contrast, stretching at e.g. a stretch factor of about1.8 (e.g. by means of wet stretching) may result in a markedly shorterlength during hydration. Stretching at e.g. a stretch factor of 4 (e.g.by means of dry stretching) could result in a much shorter length uponhydration (such as, for example, a reduction in length from 15 to 8 mm).One skilled in the art will appreciate that other factors besidesstretching can also affect swelling behavior.

Among other factors influencing the possibility to stretch the hydrogeland to elicit dimensional change of the implant upon hydration is thecomposition of the polymer network. In the case PEG precursors are used,those with a lower number of arms (such as 4-armed PEG precursors)contribute in providing a higher flexibility in the hydrogel than thosewith a higher number of arms (such as 8-armed PEG precursors). If ahydrogel contains more of the less flexible components (e.g. a higheramount of PEG precursors containing a larger number of arms, such as the8-armed PEG units), the hydrogel may be firmer and less easy to stretchwithout fracturing. On the other hand, a hydrogel containing moreflexible components (such as PEG precursors containing a lower number ofarms, such as 4-armed PEG units) may be easier to stretch and softer,but also swells more upon hydration. Thus, the behavior and propertiesof the implant once it has been placed into the eye (i.e., once thehydrogel becomes (re-)hydrated) can be tailored by means of varyingstructural features as well as by modifying the processing of theimplant after it has been initially formed.

Exemplary dimensions of implants used in the Examples herein below areprovided inter alia in Tables 6, 21.1 and 21.2 of the Examples section.Specific implants containing about 200 μg and about 600 μg axitinib aredisclosed in Tables 21.1 and 21.2. Implants containing about 200 μg orabout 600 μg axitinib may however also have dimensions (i.e., lengthsand/or diameters) differing from the dimensions disclosed in theseTables. The dried implant dimensions inter alia depend on the amount ofTKI incorporated as well as the ratio of TKI to polymer units and canalso be controlled by the diameter and shape of the mold or tubing inwhich the hydrogel is allowed to gel. Furthermore, the diameter of theimplant is further determined inter alia by (wet or dry) stretching ofthe hydrogel strand once formed. The dried strand (after stretching) iscut into segments of the desired length to form the implant; the lengthcan thus be chosen as desired.

In the following, embodiments of implants with specific dimensions aredisclosed. Whenever the dimensional ranges or values disclosed hereinrelate to the length and the diameter of an implant, the implant iscylindrical or essentially cylindrical. However, all values and rangesdisclosed herein for lengths and diameters of cylindrical implants mayequally be used for lengths and widths, respectively, of non-cylindricalimplants as also disclosed herein.

In certain embodiments, an implant of the present invention may have inits dry state a length of less than about 17 mm. In specificembodiments, the length of an implant in its dry states may be less thanabout 15 mm, or less than or equal to about 12 mm, or less than or equalto about 10 mm, or less than or equal to about 8.5 mm. In specificembodiments, an implant of the present invention may have in its drystate a length of about 12 to about 17 mm, or may have in its dry statea length of about 6 mm to about 10 mm or specifically of about 6 mm toabout 9 mm.

In certain embodiments, an implant of the present invention may have inits dry state a diameter of about 0.1 mm to about 0.5 mm. In certainother embodiments, an implant in its dry state may have a diameter ofabout 0.2 mm to about 0.5 mm. In specific embodiments, an implant in itsdry state may have a diameter of about 0.2 mm to about 0.4 mm, or ofabout 0.3 mm to about 0.4 mm. In specific embodiments, an implant of thepresent invention may have a diameter in the dry state of about 0.2 mmto about 0.3 mm, or of about 0.3 mm to about 0.4 mm.

In particular embodiments, an implant in its dry state may have a lengthof about 6 mm to about 10 mm and a diameter of about 0.2 to about 0.4mm.

In certain embodiments, an implant of the present invention may have inits wet/hydrated state a length of about 6 mm to about 12 mm. In certainother embodiments, an implant of the present invention may have in itswet/hydrated state a length of equal to or less than about 10 mm, or ofabout 6 mm to about 10 mm. In specific embodiments, an implant of thepresent invention in its wet/hydrated state may have a length of about 6mm to about 8 mm.

In certain embodiments, an implant of the present invention may have inits wet/hydrated state a diameter of equal to or less than about 0.8 mm,or of about 0.5 mm to about 0.8 mm, or of about 0.65 mm to about 0.8 mm.In specific embodiments, an implant of the present invention may have adiameter in its wet/hydrated state of about 0.7 mm to about 0.8 mm.

In particular embodiments, an implant in its wet/hydrated state may havea length of equal to or less than about 10 mm and a diameter of equal toor less than about 0.8 mm.

In embodiments of the present invention, the diameter of an implant inits dry state must be such that the implant can be loaded into athin-diameter needle as disclosed herein, such as a 25-gauge or 27-gaugeneedle. Specifically, in one embodiment an implant containing from about480 μg to about 750 μg axitinib may have a diameter such that it can beloaded into a 25-gauge needle, or that it can be loaded into a 27-gaugeneedle without afflicting any damage to the implant while loading, andsuch that the implant remains stably in the needle during furtherhandling (including packaging, sterilization, shipping etc.).

Whenever herein a length or a diameter of an implant of the invention inthe wet/hydrated state is disclosed (in mm), this disclosure refers tothe implant's length or the diameter, respectively, determined after 24hours at 37° C. at pH 7.2. It is understood that in this context a pH of7.2 comprises a pH range of about 7.2 to about 7.4.

The dimensions of an implant may further change (e.g. the length mayincrease slightly again) over the course of time (i.e., after 24 hours)when the implant remains in these conditions. However, whenever hydrateddimensions of an implant are reported herein, these are measured after24 hours at a pH of 7.2 at 37° C. in PBS as disclosed above.

In case several measurements of the length or diameter of one implantare conducted, or several datapoints are collected during themeasurement, the average (i.e., mean) value is reported as definedherein. The length and diameter of an implant according to the inventionmay be measured e.g. by means of microscopy, or by means of an(optionally automated) camera system as described in Example 6.1.

In certain embodiments, an implant of the present invention may have aratio of the diameter in the hydrated state to the diameter in the drystate of less than about 5 mm, or less than about 4 mm, or less thanabout 3.25 mm, or less than about 2.5 mm, or less than about 2.25 mm, orless than about 2.10 mm.

In certain same or other embodiments, an implant of the presentinvention may have a ratio of the length in the dry state to the lengthin the hydrated state of greater than about 0.7, or greater than about0.8, or greater than about 0.9, or greater than about 1.0. In certainspecific embodiments, the ratio of the length of an implant in the drystate to the length of the implant in the hydrated state may be greaterthan about 1.5, or even greater than about 2.0. This ratio of length inthe dry state to length in the hydrated state may apply in addition to,or independently of, the ratio of the diameter in the hydrated state tothe diameter in the dry state disclosed above.

A small diameter in the dry state may be advantageous as the implant mayfit into a small diameter needle for injection as disclosed herein, suchas a 25-gauge or a 27-gauge needle. Also, only moderate swelling uponhydration may be advantageous for the implant to not occupy too muchspace in the vitreous humor. A relatively shorter length of the implantmay be advantageous in reducing the potential likelihood for contactwith the retina.

In one embodiment, an implant of the present invention contains fromabout 160 μg to about 250 μg, or from about 180 μg to about 220 μg, orabout 200 μg axitinib, is in the form of a fiber (or cylinder) and has alength of about 14.5 mm to about 17 mm, or of about 15 mm to about 16.5mm and a diameter of about 0.20 mm to about 0.30 mm in the dried state.Such an implant may decrease in length and increase in diameter uponhydration in vivo in the eye, such as in the vitreous humor, or in vitro(wherein hydration in vitro is measured in phosphate-buffered saline ata pH of 7.2 at 37° C. after 24 hours) to a length of about 6.5 mm toabout 8 mm or of about 7 mm to about 8.5 mm, and a diameter of about0.65 mm to about 0.8 mm, or of about 0.70 to about 0.80 mm. In oneembodiment, this dimensional change may be achieved by dry stretching asdisclosed herein at a stretch factor of about 2 to about 5, or a stretchfactor of about 3 to about 4.5.

In another embodiment, an implant of the present invention contains fromabout 480 μg to about 750 μg, or from about 540 μg to about 660 μg, orabout 600 μg of axitinib, is in the form of a fiber (cylinder) and inits dried state may have a length of in the range of from about 6 mm orabout 7 mm to about 12 mm and a diameter of about 0.25 mm to about 0.50mm, or a length of about 7 mm to about 10 mm, or of about 8 mm to about11 mm, and a diameter of about 0.3 mm to about 0.4 mm. In specificembodiments, an implant of the present invention that contains fromabout 480 μg to about 750 μg, or from about 540 μg to about 660 μg, orabout 600 μg of axitinib, is in the form of a fiber (cylinder) and inits dried state may have a length of from about 7 mm to about 10 mm,such as from about 7 mm to about 9 mm, and a diameter of from about 0.3mm to about 0.4 mm, such as from about 0.35 mm to about 0.39 mm.

Such an implant may increase in diameter upon hydration in vivo in theeye, such as in the vitreous humor, or in vitro (wherein hydration invitro is measured in phosphate-buffered saline at a pH of 7.2 at 37° C.after 24 hours) while its length may be essentially maintained or may bereduced, or only slightly increased to a length of e.g. in the range offrom about 6 mm or about 9 mm to about 12 mm and a diameter of about 0.5mm to about 0.8 mm, or a length of about 9.5 mm to about 11.5 mm and adiameter of from about 0.65 mm to about 0.75 mm or about 0.8 mm in itshydrated state. In specific embodiments, an implant of the presentinvention that contains from about 480 μg to about 750 μg, or from about540 μg to about 660 μg, or about 600 μg of axitinib and is in the formof a fiber (cylinder) in its hydrated state (i.e., at a pH of 7.2 at 37°C. after 24 hours as explained above) may have a length of from about 6mm to about 10.5 mm, such as from about 6.5 mm to about 8.5 mm, and adiameter from about 0.7 mm to about 0.8 mm.

In one embodiment, the length of an implant of the present inventionthat contains from about 480 μg to about 750 μg, or from about 540 μg toabout 660 μg, or about 600 μg of axitinib in the dried state is nolonger than 10 mm, and in the hydrated state (as measured inphosphate-buffered saline at a pH of 7.2 at 37° C. after 24 hours) isalso no longer or not substantially longer than about 10 mm, or nolonger than about 9 mm, or no longer than about 8 mm.

In one or more embodiment(s), the above-described dimensional change canbe achieved by wet stretching at a stretch factor of about 0.5 to about5, or a stretch factor of about 1 to about 4, or a stretch factor ofabout 1.3 to about 3.5, or a stretch factor of about 1.7 to about 3, ora stretch factor of about 2 to about 2.5. In other embodiments theimplant of the present invention containing from about 480 μg to about750 μg, or from about 540 μg to about 660 μg, or about 600 μg ofaxitinib may be longer than about 12 mm in the dry state, but may end upbeing shorter than about 10 mm or about 9 mm in the hydrated state.

In certain embodiments, the stretching thus creates a shape memory,meaning that the implant upon hydration when administered into the eye,e.g., into the vitreous cavity, will shrink in length and widen indiameter until it approaches (more or less) its equilibrium dimensions,which are determined by the original molded dimensions and compositionalvariables. While the narrow dry dimensions facilitate administration ofthe product through a small gauge needle, the widened diameter andshortened length after administration yield a shorter implant (such asabout 9 to 10 mm long, or at least not much longer than that) in theposterior chamber of the eye relative to the eye diameter minimizingpotential contact with surrounding eye tissues. Thus, in one aspect thepresent invention also relates to a method of imparting shape memory toa hydrogel fiber comprising an active agent such as a TKI, e.g.axitinib, dispersed in the hydrogel by stretching the hydrogel fiber inthe longitudinal direction. In another aspect the present inventionrelates to a method of manufacturing an ocular implant comprising ahydrogel comprising an active agent, such as a TKI, e.g. axitinib,dispersed therein, wherein the implant changes its dimensions uponadministration to the eye, the method comprising preparing a fiber ofthe hydrogel and stretching the fiber in the longitudinal direction.

In Vitro Release:

The in vitro-release of TKI from the implants of the invention can bedetermined by various methods disclosed in detail in Example 2:

Briefly, one method to determine the in vitro release of the TKI fromthe implant is under non-sink simulated physiological conditions in PBS(phosphate-buffered saline, pH 7.2) at 37° C., with daily replacement ofPBS in a volume comparable to the vitreous volume in the human eye.Results for exemplary implants are shown in FIG. 4A. In the testedimplants comprising axitinib in a PEG hydrogel matrix as described inExample 2 the higher dose strengths resulted in higher axitinibconcentrations in the release medium.

Generally, in embodiments of the invention, an implant according theinvention may release on average about 0.1 μg to about 3 μg, or about0.25 μg to about 2.5 μg, or about 0.1 μg to about 2 μg, or may releaseabout 0.25 μg to about 1.5 μg per day in vitro in PBS at pH 7.2 and 37°C. for a period of 30 days.

In one embodiment, an implant according to the invention containingabout 200 μg axitinib, may release on average in vitro about 0.01 μg toabout 0.15 μg of axitinib per day in phosphate-buffered saline at pH 7.2and 37° C. for a period of 30 days.

In one embodiment, an implant according to the invention containingabout 600 μg axitinib may release on average in vitro about 0.3 μg toabout 0.5 μg of axitinib per day in phosphate-buffered saline at pH 7.2and 37° C. for a period of 30 days.

In an accelerated in vitro test, also described in detail in Example 2,the release of the TKI from the implant can be determined in a 25:75ethanol/water mixture (v/v) at 37° C. This accelerated in vitro test canbe completed in about 2 weeks. FIG. 14B shows the accelerated in vitrorelease data for an implant according to the invention containing about200 μg axitinib, and FIG. 4B the accelerated in vitro release data foran implant according to the invention containing about 556 μg axitinib.

In one embodiment, an implant according to the invention containingabout 200 μg axitinib releases in vitro about 35% to about 45% of theaxitinib in 3 days, about 65% to about 75% of the axitinib in 7 days,and about 90% to about 100% of the axitinib in 12 to 13 days in a 25:75ethanol/water mixture (v/v) at 37° C.

In one embodiment, an implant according to the invention containingabout 600 μg axitinib releases in vitro about 40% to about 60% of theaxitinib in 2 days, about 65% to about 85% of the axitinib in 4 days,and about 75% to about 90% of the axitinib in 6 days in a 25:75ethanol/water mixture (v/v) at 37° C. An implant according to theinvention containing about 600 μg axitinib may also release in vitroabout 45% to about 55% of the axitinib in 2 days, about 70% to about 80%of the axitinib in 4 days, and about 80% to about 90% of the axitinib in6 days in a 25:75 ethanol/water mixture (v/v) at 37° C.

Finally, the release of TKI from implants of the present invention canalso be determined under real-time sink simulated physiologicalconditions, as also described in detail in Example 2. For this real-timetest, release of the TKI is determined in PBS (pH 7.2)/0.01% NaF at 37°C. with an octanol top layer on the PBS. This is one method toqualitatively simulate release of the TKI from the implant into thevitreous humor and from there resorption of the TKI into ocular tissue.An exemplary real-time release profile for an implant according to thepresent invention containing about 200 μg axitinib is shown in FIG. 14A.

In one embodiment, an implant according to the invention containingabout 200 μg axitinib releases in vitro about 25% to about 35% of theaxitinib in 2 months, about 47% to about 57% of the axitinib in 3months, about 70% to about 80% of the axitinib in 5 months, and about90% to about 100% of the axitinib in 7 months in phosphate bufferedsaline at a pH of 7.2, at 37° C. and with an octanol top layer.

The in vitro release tests, especially the accelerated in vitro releasetest described herein, may be used inter alia to compare differentimplants (e.g. of different production batches, of differentcomposition, and of different dosage strength etc.) with each other, forexample for the purpose of quality control or other qualitativeassessments.

In Vivo Release and Persistence:

In an embodiment of the present invention, when the dried implant of thepresent invention is administered to the eye, such as the vitreoushumor, it becomes hydrated and changes its dimensions as disclosedabove, and is then over time biodegraded until it has been fullyresorbed. When the implant is biodegraded, such as through esterhydrolysis, it gradually may swell and soften, then become smaller,softer and more liquid until it is fully dissolved and no longervisible. As recognized by the inventors from the animal studiespresented in the Examples section herein below, an implant according tothe invention may persist about 2 to about 6 months, or about 5 to about6 months in rabbit eyes (see FIGS. 7A, 9 and 10). After full degradationof the implant, undissolved axitinib particles may remain at the formersite of the implant and have been observed to agglomerate, i.e., mergeinto a monolithic structure. These remaining undissolved axitinibparticles may continue to dissolve slowly at a rate sufficient toprovide therapeutically effective axitinib levels. If in certainembodiments two or more implants are administered to achieve a desiredtotal dose, they are equally biodegraded over time, and the remainingaxitinib particles also merge into one single monolithic structure (seeFIG. 9).

In the human eye, such as in the vitreous humor, the implant of theinvention in certain embodiments biodegrades within about 2 to about 15months after administration, or within about 4 to about 13 months afteradministration, or within about 9 to about 12 months afteradministration, specifically within about 9 to about 10.5 months afteradministration. This has been demonstrated in the clinical trials withone or two implant(s), each comprising about 200 μg axitinib. See theExamples section, in particular Example 6 and FIG. 15.

In one embodiment, the implant after administration to the vitreoushumor releases (as defined herein) the TKI, such as a therapeuticallyeffective amount of TKI, such as axitinib, over a period of at leastabout 3 months, at least about 6 months, at least about 9 months, atleast about 10 months, at least about 11 months, or at least about 12months, or at least about 13 months or longer after administration. Inparticular embodiments, the implant releases the TKI, such as axitinib,for a period of about 6 to about 9 months.

In one embodiment of the invention, the implant provides for a treatmentperiod of at least about 3 months, at least about 9 months, at leastabout 10 months, at least about 11 months, at least about 12 months, orat least about 13 months or longer after administration of the (i.e., asingle) implant into the vitreous humor of a patient.

In one embodiment of the invention, TKI, such as axitinib is releasedfrom the implant at an average rate of about 0.1 μg/day to about 10μg/day, or about 0.5 μg/day to about 7 μg/day, or about 0.5 μg/day toabout 2 μg/day, or about 1 μg/day to about 5 μg/day in the vitreoushumor, over a time period of at least 3, or at least 6, or at least 9,or at least 11, or at least 12, or at least 13 months. In particularembodiments the release of TKI, such as axitinib, is maintained forabout 6 to about 9 months after administration of the implant.

Pre-clinical studies in animals as well as clinical studies in humans,as presented in the Examples section herein, have shown that theimplants of the invention may continuously release therapeuticallyeffective amounts of TKI over an extended period of time, until theimplants are fully biodegraded. Any remaining undissolved TKI particles(if present) may essentially remain at the site of the former implantand may agglomerate to form an essentially monolithic structure (seeFIGS. 7A, 9 and 10) that may continue to release TKI into the vitreousat levels sufficient to achieve the therapeutic effect. In certainembodiments, however, the entire amount of TKI contained in the implantis released from the implant prior to complete biodegradation of theimplant. In this case, no undissolved TKI particles would remain (and/oragglomerate) near the site of the former implant or elsewhere in the eyeafter complete biodegradation of the implant.

In one embodiment, the persistence of the hydrogel within an aqueousenvironment and in the human eye depends inter alia on thehydrophobicity of the carbon chain in proximity to the degradable estergroup. In the implants used in the Examples herein, this carbon chaincomprises 7 carbon atoms as it stems from the SAZ functional group ofthe 4a20k PEG precursor. This may provide an extended persistence in thehuman eye of up to about 9 to about 12 months, or from about 9 to about10.5 months. In other embodiments, different precursors than the4a20kPEG-SAZ and the 8a20kPEG-NH₂ may be used to prepare hydrogelimplants that biodegrade in the human eye and have similar or differentpersistence as the implants exemplified in the Examples.

In certain embodiments, the hydrogel implant softens over time as itdegrades, which may depend inter alia on the structure of the linkerthat crosslinks the PEG units in the hydrogel. An implant as used in theexamples of the present application formed from a 4a20kPEG-SAZ and a8a20kPEG-NH₂ softens rather slowly over time.

Mechanism of Release:

Without wishing to be bound by theory, the mechanism of release of theTKI from an implant of the invention may be explained as follows: Inembodiments of the invention, release of the TKI into the eye and intothe vitreous humor is dictated by diffusion and drug clearance. Anexemplary TKI according to the present invention is axitinib. Thesolubility of axitinib has been determined to be very low inphysiological medium (about 0.4 to about 0.5 μg/mL in PBS at pH 7.2).According to the present invention, the TKI, such as axitinib, isconfined in a biodegradable hydrogel having a particular geometry andsurface. The liquid in the posterior chamber of the eye is viscous, hasa slow clearance and a relatively stagnant flow (at least as compared tothe anterior chamber of the eye).

In certain embodiments, the implant of the present invention comprises ahydrogel made of a polymer network and a drug dispersed within thehydrogel. The drug gradually gets dissolved and diffuses out of thehydrogel into the eye. This may happen first at the outer region of thehydrogel (i.e., the drug particles that are located in the outermostregion of the hydrogel get dissolved and diffuse out first, theinnermost last) that is in contact with the liquid environment of thevitreous. Thereby, in certain embodiments, the outer region of thehydrogel becomes devoid of drug particles. This region is therefore alsocalled the “clearance zone”, which is limited to dissolved drug only,with a concentration at or below the solubility of the drug. In certainembodiments, this low surface concentration may protect tissue (retinalor other cells) from potential drug toxicity by physically separatingdrug particles from the tissue should the implant get in contact withsuch tissue. In other embodiments, upon hydration the “clearance zone”is an outer region that has a concentration of active agent that is lessthan the active agent in an inner region of the hydrated hydrogel.

In embodiments with clearance zones, because drug has dissolved and hasdiffused out of the clearance zone, this area of the hydrogel developsvoids and becomes softer and weaker. Concurrently with the drugdiffusing out of the hydrogel, the hydrogel may also be slowly degradedby means of, e.g., ester hydrolysis in the aqueous environment of theeye. This degradation occurs uniformly throughout the bulk of thehydrogel. At advanced stages of degradation, distortion and erosion ofthe hydrogel begins to occur. As this happens, the hydrogel becomessofter and more liquid (and thus its shape becomes distorted) until thehydrogel finally dissolves and is resorbed completely. This process isschematically shown on FIG. 3 and demonstrated by means of infraredreflectance (IR) imaging e.g. in FIG. 10.

As axitinib is a relatively low solubility drug, undissolved axitinibparticles may remain at the former site of the implant after the implanthas already fully degraded in certain embodiments. Since these remainingundissolved axitinib particles are no longer fixated and held apart bythe hydrogel, they may agglomerate and form a substantially monolithicstructure. This monolithic axitinib structure may still continue torelease axitinib, at rates sufficient to achieve the therapeutic effect(specifically, to reduce CSFT).

In one embodiment, however, the entire amount of axitinib is releasedprior to the complete degradation of the hydrogel. As the hydrogel mayhold the axitinib particles in place and prevent them from agglomerationthe release of axitinib from the hydrogel can be faster as long as thehydrogel has not yet fully degraded. When the hydrogel has fullydegraded, remaining axitinib particles may form a monolithic structurefrom which axitinib may slowly be dissolved. Therefore, complete releaseof the axitinib prior to full degradation of the hydrogel is desired inone embodiment of the invention.

This whole process makes it possible in certain embodiments toadvantageously maintain the therapeutic effect of the implant of thepresent invention over an extended period of time, such as at least 3months, or at least 6 months, or at least 9 months, or at least 11months, or at least 12 months, or at least 13 months, or at least 14months, or even longer, such as up to 15 months. It has beendemonstrated by the present inventors that this is a great advantage forpatients receiving treatment for neovascular age-related maculardegeneration, which treatment previously involved very frequentintravitreal injections of an anti-VEGF agent. In contrast, the implantsaccording to the present invention may need to be injected only at muchgreater intervals of time, which is advantageous for the patient for anumber of reasons as already disclosed above in the section “Objects andSummary”.

Specific Implant Containing from about 160 μg to about 250 μg Such asabout 200 μg Axitinib:

In one particular embodiment, the present invention relates to asustained release biodegradable ocular implant containing axitinib in anamount in the range from about 160 μg to about 250 μg, or from about 180μg to about 220 μg, and specifically about 200 μg dispersed in ahydrogel, wherein the hydrogel comprises a polymer network comprisingpolyethylene glycol units, and wherein the implant is in a dried state.In this embodiment the polymer network contains polyethylene glycolunits comprising multi-arm polyethylene glycol units, such as 4-armand/or 8-arm polyethylene glycol units having an average molecularweight in the range of from about 10,000 Daltons to about 60,000Daltons. In this embodiment, the polymer network of this implant isformed by reacting 4a20kPEG-SAZ with 8a20kPEG-NH₂, at a weight ratio ofabout 2:1. In this embodiment the hydrogel when formed and before beingdried (i.e., the wet composition) contains about 6.5% to about 7.5%polyethylene glycol, representing the polyethylene glycol weight dividedby the fluid weight×100. Also, in this embodiment the implant in a driedstate contains from about 45% to about 55% by weight axitinib and fromabout 37% to about 47% by weight polyethylene glycol units, or fromabout 47% to about 52% by weight axitinib and from about 40% to about45% by weight polyethylene glycol units, such as about 49% to about 50%by weight axitinib and about 42% by weight PEG units, or about 47% byweight axitinib and about 44% by weight PEG units (dry composition), thebalance being sodium phosphate. The implant furthermore in its driedstate may contain not more than about 1% by weight water, or not morethan about 0.25% by weight water.

In this embodiment, the implant containing axitinib in an amount in therange from about 160 μg to about 250 μg, or from about 180 μg to about220 μg, and specifically about 200 μg releases in vitro about 0.01 μg toabout 0.15 μg of axitinib per day in phosphate-buffered saline at 37° C.for a period of 30 days. Furthermore, in this embodiment the implantreleases in vitro about 35% to about 45% of the axitinib in 3 days,about 65% to about 75% of the axitinib in 7 days, and about 90% to about100% of the axitinib in 12 to 13 days in a 25:75 ethanol/water (v/v)mixture at 37° C. In this embodiment the implant may also release invitro about 25% to about 35% of the axitinib in 2 months, about 47% toabout 57% of the axitinib in 3 months, about 70% to about 80 of theaxitinib in 5 months, and about 90% to about 100% of the axitinib in 7months in phosphate buffered saline at a pH of 7.2, at 37° C. and withan octanol top layer.

In this embodiment, the implant containing about 200 μg axitinib may bein the form of a fiber (or cylinder) and may have a length of less thanabout 20 mm, or less than about 17 mm, or of about 15 mm to about 16.5mm and a diameter of about 0.20 mm to about 0.30 mm in its dried stateand may decrease in length and increases in diameter upon hydration invivo in the vitreous humor or in vitro (wherein hydration in vitro ismeasured in phosphate-buffered saline at a pH of 7.2 at 37° C. after 24hours) to a length of about 6.5 mm to about 8 mm and a diameter of about0.70 mm to about 0.80 mm in the hydrated state. This dimensional changeupon hydration may be achieved by imparting shape memory to the implantby dry stretching the implant in the longitudinal direction as explainedin more detail elsewhere herein, by a stretch factor of about 2 to about5, or a stretch factor of about 3 to about 4.5. In other embodiments,the implant may be non-cyclindrical.

In this embodiment, the implant containing about 200 μg axitinib mayhave a ratio of the diameter in the hydrated state to the diameter inthe dry state of less than about 3.25 mm, and/or a ratio of the lengthin the dry state to the length in the hydrated state of greater thanabout 1.5.

The total weight of an implant as disclosed in this embodiment in itsdry state may be from about 0.3 mg to about 0.6 mg, such as from about0.4 mg to about 0.5 mg. Such an implant in the dry state may containabout 10 μg to about 15 μg of axitinib per 1 mm final length, and maycontain from about 200 μg to about 300 μg axitinib per mm³.

In this embodiment, prior to administration, the implant containing anaxitinib dose of about 200 μg is loaded into a 25-gauge needle or a27-gauge needle (or an even smaller gauge needle, such as a 30-gaugeneedle) for injection into the vitreous humor.

To summarize and exemplify, the individual characteristics of an implantof the invention disclosed with respect to the embodiment described inthis section containing a dose of about 200 μg (including the implantthat is used in the clinical study presented in Example 6) are providedin Table 21.1 in the Examples section, which is also reproduced here:

Implant type Implant #1 Formulation Axitinib 49.4%  (% dry Dose (200 μg)basis w/w) PEG Hydrogel 42.0%  4a20K PEG-SAZ  28% 8a20K PEG-NH2  14%Sodium phosphate 8.6% Formulation Axitinib 7.5% (% wet PEG Hydrogel 6.9%basis w/w) 4a20K PEG-SAZ 4.6% 8a20K PEG-NH2 2.3% Sodium phosphate 1.5%WFI 84.1%  Axitinib per final 12.1 μg/mm dry length Approximate 423   Implant Mass (dose μg/API %) Configuration Stretching Method Dry(Stretch Factor) (4.5) Needle Size 27G TW 1.25″ (0.27 mm ID)Injector/Syringe Implant Injector Packaging Foil Pouches SterilizationType Gamma Site Storage Refrigerated Dimensions Dried Diameter 0.24 ±0.013 mm Length 16.5 ± 0.26 mm Volume 0.75 ± 0.08 mm³ Implant Mass 0.45mg Axitinib per volume 266.7   (μg/mm³) Hydrated Diameter 0.75 mm Length7.5 mm Ratio of diameter 3.13 (hydrated) to diameter (dry) Ratio oflength (dry) 2.20 to length (hydrated)

The sustained release biodegradable ocular implant of claim 1, whereinthe implant is an intravitreal implant and comprises from about 180 μgto about 220 μg axitinib, is cylindrical and has in its dry state alength of less than about 17 mm and a diameter of about 0.2 mm to about0.3 mm, and in its hydrated state (after 24 hours in phosphate-bufferedsaline at a pH of 7.2 at 37° C.) has a length of from about 6.5 mm toabout 8 mm and a diameter of from about 0.7 mm to about 0.8 mm, andwherein the hydrogel comprises crosslinked 4a20k and 8a20k PEG units,wherein the crosslinks between the PEG units include a group representedby the following formula

wherein m is 6.

Alternatively, an implant of this particular embodiment may also benon-cyclindrical as disclosed herein.

Specific Implant Containing about 480 μg to about 750 μg Such as about600 μg Axitinib:

In another particular embodiment, the present invention relates to asustained release biodegradable ocular implant containing axitinib in anamount in the range from about 480 μg to about 750 μg dispersed in ahydrogel, wherein the hydrogel comprises a polymer network thatcomprises crosslinked polyethylene glycol units. The amount of axitinibin said implant may also be in the range from about 540 μg to about 660μg, or may specifically be about 600 μg.

In this implant, the polyethylene glycol units comprise multi-armpolyethylene glycol units, such as 4-arm and/or 8-arm polyethyleneglycol units having an average molecular weight in the range of fromabout 10,000 Daltons to about 60,000 Daltons. In this embodiment, thepolymer network of the implant comprises 4a20kPEG and 8a20kPEG units andis formed by reacting 4a20kPEG-SAZ with 8a20kPEG-NH₂, in a weight ratioof about 2:1.

In this embodiment, the implant in a dried state may contain from about45% to about 55% by weight axitinib and from about 37% to about 47% byweight polyethylene glycol units, or may contain from about 60% to about75% by weight axitinib and from about 21% to about 31% polyethyleneglycol units, such as from about 63% to about 72% by weight axitinib andfrom about 23% to about 27% polyethylene glycol units (dry composition),the balance being sodium phosphate. In certain specific embodiments theimplant may contain about 68% to about 69% axitinib and about 26%polyethylene glycol units (dry composition), the balance being sodiumphosphate. The implant may contain not more than about 1% by weightwater, or not more than about 0.25% by weight water.

In this embodiment, this implant containing axitinib in an amount in therange from about 480 μg to about 750 μg, or from about 540 μg to about660 μg, or specifically about 600 μg releases in vitro about 0.3 μg toabout 0.5 μg of axitinib per day in phosphate-buffered saline at 37° C.for a period of 30 days. Furthermore, this implant releases in vitroabout 40% to about 60% of the axitinib in 2 days, about 65% to about 85%of the axitinib in 4 days, and about 75% to about 90% of the axitinib in6 days in a 25:75 (v/v) ethanol/water mixture at 37° C. In thisembodiment, this implant may also release in vitro about 45% to about55% of the axitinib in 2 days, about 70% to about 80% of the axitinib in4 days, and about 80% to about 90% of the axitinib in 6 days in a 25:75ethanol/water (v/v) mixture at 37° C.

In this embodiment, the implant containing about 600 μg axitinib may bein the form of a fiber (or cylinder) and may have in its dried state alength of less than about 20 mm, or less than about 17 mm, or less thanabout 15 mm, or less than or equal to about 12 mm, such as about 7 mm toabout 12 mm and a diameter of about 0.25 mm to about 0.50 mm, or alength of from about 7 mm or about 8 mm to about 11 mm and a diameter ofabout 0.3 mm to about 0.4 mm, and may increase in diameter uponhydration in vivo in the vitreous humor or in vitro (wherein hydrationin vitro is measured in phosphate-buffered saline at a pH of 7.2 at 37°C. after 24 hours). In specific embodiments, an implant containing about600 μg of axitinib in its dried state may have a length of less than orequal to about 10 mm, or less than or equal to about 8.5 mm, or fromabout 7 mm to about 9 mm, or from about 7 mm to about 8.5 mm and adiameter of from about 0.3 mm to about 0.4 mm, such as from about 0.35mm to about 0.39 mm.

The dimensions of this implant after hydration in vivo or in vitro(wherein in vitro hydration is measured in phosphate-buffered saline ata pH of 7.2 at 37° C. after 24 hours) may be a length of less than orequal to about 10 mm, such as of from about 6 mm or about 9 mm to about12 mm and a diameter of about 0.5 mm to about 0.8 mm, or a length ofabout 9.5 mm to about 11.5 mm, or a length of not more than about 10 mmor not more than about 9 mm, and a diameter of from about 0.65 mm toabout 0.75 mm or to about 0.80 mm. In specific embodiments, an implantcontaining about 600 μg of axitinib in its hydrated state (whereinhydration in vitro is measured in phosphate-buffered saline at a pH of7.2 at 37° C. after 24 hours) may have a length of from about 6 mm toabout 10.5 mm, such as from about 6.5 mm to about 8.5 mm, and a diameterof from about 0.7 mm to about 0.8 mm. In particular embodiments, alength of about 10 mm or less, such as about 9 mm or less when hydratedin the vitreous humor of the eye is an acceptable length given thelimited volume of the eye.

This dimensional change upon hydration may be achieved by wet stretchingin the longitudinal direction prior to drying as disclosed in moredetail below by a stretch factor of about 0.5 to about 5, or a stretchfactor of about 1 to about 4, or a stretch factor of about 1.3 to about3.5, or a stretch factor of about 1.7 to about 3, or a stretch factor ofabout 2 to about 2.5.

In this embodiment, the implant containing about 600 μg axitinib mayhave a ratio of the diameter in the hydrated state to the diameter inthe dry state of less than about 2.25 mm and/or a ratio of the length inthe dry state to the length in the hydrated state of greater than 0.75.

The total weight of an implant as disclosed herein containing about 600μg axitinib may in the dry state be from about 0.8 mg to about 1.1 mg,such as from about 0.9 mg to about 1.0 mg. Such an implant in the drystate may contain about 70 μg to about 85 μg of axitinib per 1 mm finallength, and may contain from about 500 μg to about 800 μg axitinib permm³.

In this embodiment, the preferred shape of the implant is cylindrical oressentially cylindrical (and may also be referred to as a fiber). Inother embodiments, the implant may be non-cylindrical. Prior toadministration, this implant containing an axitinib dose of about 600 μgis loaded into a 25-gauge (or a smaller gauge, such as a 27-gauge)needle for injection into the eye, e.g., the vitreous humor.

To summarize, the individual characteristics of implants of theinvention disclosed with respect to the embodiment described in thissection containing a dose of about 600 μg axitinib are provided in Table21.2 in the Examples section, which is also reproduced here:

Implant type Implant #2 Implant #3 Implant #4 Formulation Axitinib49.8%  68.6%  68.6%  (% dry Dose (600 μg) (600 μg) (600 μg) basis w/w)PEG Hydrogel 42.0%  26.0%  26.0%  4a20K PEG-SAZ  28% 17.4%  17.4%  8a20KPEG-NH2  14% 8.7% 8.7% Sodium phosphate 8.2% 5.4% 5.4% FormulationAxitinib 12.0%  16.5%  16.5%  (% wet PEG Hydrogel 6.3% 6.3% 6.3% basisw/w) 4a20K PEG-SAZ 4.2% 4.2% 4.2% 8a20K PEG-NH2 2.1% 2.1% 2.1% Sodiumphosphate 1.3% 1.3% 1.3% WFI 80.4%  75.9%  75.9%  Axitinib per final71.4 μg/mm 71.4 μg/mm 81.1 μg/mm dry length Approximate 1205     875   875    Implant Mass (dose ug/API %) Configuration Stretching Method WetWet Wet (Stretch Factor) (2.1) (2.1) (2.1) Needle Size 25G UTW 1″ 25GUTW 1″ 25G UTW 0.5″ (0.4 mm ID) (0.4 mm ID) (0.4 mm ID) Injector/SyringeImplant Injector Implant Injector Implant Injector Packaging FoilPouches Foil Pouches Foil Pouches Sterilization Type Gamma Gamma GammaSite Storage Refrigerated Refrigerated Refrigerated Dimensions DriedDiameter 0.36 mm 0.37 ± 0.014 mm 0.37 ± 0.008 mm Length 8.4 mm 8.4 ±0.04 mm 7.4 ± 0.03 mm Volume 0.86 mm³ 0.90 ± 0.07 mm³ 0.81 ± 0.05 mm³Implant Mass 1.20 mg 0.95 ± 0.04 mg 0.95 ± 0.01 mg Axitinib per volume697.7   666.7   740.7   (μg/mm³) Hydrated Diameter 0.7 mm 0.68 mm 0.77mm Length 10 mm 8.23 mm 6.8 mm Ratio of diameter 1.94 1.84 2.08(hydrated) to diameter (dry) Ratio of length (dry) 0.84 1.02 1.09 tolength (hydrated)

In a particular embodiment, the sustained release biodegradable ocularimplant of the present invention is an intravitreal implant andcomprises from about 540 μg to about 660 μg axitinib, is cylindrical andhas in its dry state a length of less than or equal to 10 mm and adiameter of about 0.3 mm to about 0.4 mm, and in its hydrated state(after 24 hours in phosphate-buffered saline at a pH of 7.2 at 37° C.)has a length of from about 6 mm to about 10.5 mm and a diameter of fromabout 0.6 mm to about 0.8 mm, and wherein the hydrogel comprisescrosslinked 4a20k and 8a20k PEG units, wherein the crosslinks betweenthe PEG units include a group represented by the following formula

wherein m is 6.

Alternatively, an implant of this particular embodiment may also benon-cyclindrical as disclosed herein.

II. Manufacture of the Implant Manufacturing Process:

In certain embodiments, the present invention also relates to a methodof manufacturing a sustained release biodegradable ocular implant asdisclosed herein. Generally, the method comprises the steps of forming ahydrogel comprising a polymer network and TKI particles dispersed withinthe hydrogel, shaping the hydrogel and drying the hydrogel. In certainembodiments the method comprises the steps of forming a hydrogelcomprising a polymer network from reactive group-containing precursors(e.g., comprising PEG units) and TKI particles dispersed in thehydrogel, shaping the hydrogel and drying the hydrogel, morespecifically the polymer network is formed by mixing and reacting anelectrophilic group-containing multi-arm PEG precursor with anucleophilic group-containing multi-arm PEG precursor or anothernucleophilic group-containing crosslinking agent (precursors andcrosslinking agent as disclosed herein in the sections “The polymernetwork” and “PEG hydrogels”) in a buffered solution in the presence ofTKI particles and allowing the mixture to gel to form the hydrogel. Inembodiments of the invention, the hydrogel is shaped into a hydrogelstrand as disclosed herein, by casting the mixture into a tubing priorto complete gelling of the hydrogel. In certain embodiments, thehydrogel strand is stretched in the longitudinal direction prior to orafter drying as further disclosed herein.

In certain embodiments, the TKI in the method of manufacturing accordingto the invention in all its aspects is axitinib. In one embodiment theTKI, such as axitinib, may be used in micronized form for preparing theimplant as disclosed herein, and may have a particle diameter as alsodisclosed herein in the section “The active principle”. In certainspecific embodiments, the axitinib may have a d90 of less than about 30μm, or less than about 10 μm. Using micronized TKI, specificallymicronized axitinib, may have the effect of reducing the tendency of theTKI, specifically axitinib, particles to agglomerate during casting ofthe hydrogel strands, as demonstrated in FIG. 24. In another embodiment,the TKI, such as axitinib, may be used in non-micronized form forpreparing the implant.

The precursors for forming the hydrogel of certain embodiments have beendisclosed in detail above in the section relating to the implant itself.In case PEG precursors are used to prepare a crosslinked PEG network,the method of manufacturing the implant in certain embodiments maycomprise mixing and reacting an electrophilic group-containing polymerprecursor, such as an electrophilic group-containing multi-armpolyethylene glycol, such as 4a20kPEG-SAZ, with a nucleophilicgroup-containing polymer precursor or other cross-linking agent, such asa nucleophilic group-containing multi-arm polyethylene glycol, such as8a20kPEG-NH₂, in a buffered solution in the presence of the tyrosinekinase inhibitor, and allowing the mixture to gel. In certainembodiments, the molar ratio of the electrophilic groups to thenucleophilic groups in the PEG precursors is about 1:1, but thenucleophilic groups (such as the amine groups) may also be used inexcess of the electrophilic groups. Other precursors, including otherelectrophilic group-containing precursors and other nucleophilicgroup-containing precursors or crosslinking agents may be used asdisclosed in the section “The polymer network” and the section “PEGhydrogels” herein.

In certain embodiments, a mixture of the electrophilic group-containingprecursor, the nucleophilic group-containing precursor or othercrosslinking agent, the TKI and optionally buffer (and optionallyadditional ingredients as disclosed in the section “Additionalingredients”) is prepared. This may happen in a variety of orders,including but not limited to first preparing separate mixtures of theelectrophilic and the nucleophilic group-containing precursors each inbuffer solution, then combining one of the buffer/precursor mixtures,such as the buffer/nucleophilic group-containing precursor mixture, withthe TKI and subsequently combining this TKI-containing buffer/precursormixture with the other buffer/precursor mixture (in this case thebuffer/electrophilic group-containing precursor mixture). After amixture of all components has been prepared (i.e., after all componentshave been combined and the wet composition has been formed), the mixtureis cast into a suitable mold or tubing prior to complete gelling of thehydrogel in order to provide the desired final shape of the hydrogel.The mixture is then allowed to gel. The resulting hydrogel is thendried.

The viscosity of the wet hydrogel composition to be cast into a mold ortubing may depend inter alia on the concentration and the solids contentof the hydrogel composition, but may also depend on external conditionssuch as the temperature. Castability of the wet hydrogel compositionespecially in case the composition is cast into fine-diameter tubing,may be improved by decreasing the viscosity of the wet composition,including (but not limited to) decreasing the concentration ofingredients in the solvent and/or decreasing the solids content, orother measures such as increasing the temperature etc. Suitable solidscontents are disclosed herein in the section “Formulation”.

In case the implant should have the final shape of a fiber (such as acylinder), the reactive mixture may be cast into a fine diameter tubing(of e.g. an inner diameter of about 1.0 mm to about 1.5 mm), such as aPU or silicone tubing, in order to provide for the extended cylindricalshape. Different geometries and diameters of the tubing may be used,depending on the desired final cross-sectional geometry of the hydrogelfiber, its initial diameter (which may still be decreased by means ofstretching), and depending also on the ability of the reactive mixtureto uniformly fill the tubing.

Thus, the inside of the tubing may have a round geometry or a non-roundgeometry, such as a cross-shaped (or other) geometry. By means of across-shaped geometry, the surface of the implant may be increased.Also, in certain embodiments, the amount of TKI incorporated in theimplant may be increased with such cross-shaped geometry. Overall, byusing a cross-shaped geometry, release of the API from the implant mayin certain embodiments be increased. Other cross-sectional geometries ofthe implant may be used as disclosed herein.

In certain embodiments, after the hydrogel has formed and has been leftto cure to complete gelling, the hydrogel strand may be longitudinallystretched in the wet or dry state as already disclosed in detail hereine.g. in the section relating to the dimensional change of the implantupon hydration. In certain embodiments, a stretching factor (alsoreferred to herein as “stretch factor”) may be in a range of about 1 toabout 4.5, or about 1.3 to about 3.5, or about 2 to about 2.5, or withinother ranges also as disclosed herein (e.g. in, but not limited to, thesection “Dimensions of the implant and dimensional change upon hydrationthrough stretching”. The stretch factor indicates the ratio of thelength of a certain hydrogel strand after stretching to the length ofthe hydrogel strand prior to stretching. For example, a stretch factorof 2 for dry stretching means that the length of the dry hydrogel strandafter (dry) stretching is twice the length of the dry hydrogel strandbefore the stretching. The same applies to wet stretching. When drystretching is performed in certain embodiments, the hydrogel is firstdried and then stretched. When wet stretching is performed in certainembodiments, the hydrogel is stretched in the wet (undried) state andthen left to dry under tension. Optionally, heat may be applied uponstretching. Further optionally, the hydrogel fiber may additionally betwisted. In certain embodiments, the stretching and/or drying may beperformed when the hydrogel is still in the tubing. Alternatively, thehydrogel may be removed from the tubing prior to being stretched. Incertain embodiments, the implant maintains its dimensions even afterstretching as long as it is kept in the dry state at or below roomtemperature.

After stretching and drying the hydrogel strand is removed from thetubing (if still located inside the tubing) and cut into segments of alength desired for the final implant in its dry state, such as disclosedherein (if cut within the tubing, the cut segments are removed from thetubing after cutting). A particularly desired length of the implant inthe dry state for the purposes of the present invention is for example alength of equal to or less than about 12 mm, or equal to or less thanabout 10 mm, as disclosed herein.

In certain embodiments, the final prepared implant is then loaded into afine diameter needle. In certain embodiments, the needle has a gaugesize of from 22 to 30, such as gauge 22, gauge 23, gauge 24, gauge 25,gauge 26, gauge 27, gauge 28, gauge 29 or gauge 30. In specificembodiments, the needle is a 25- or 27-gauge needle, or an even smallergauge needle, such as a 30-gauge needle, depending on the diameter ofthe dried (and optionally stretched) implant.

In certain embodiments, the needles containing implant are thenseparately packaged and sterilized e.g. by means of gamma irradiation.

In certain embodiments, an injection device, such as a syringe oranother injection device, may be separately packaged and sterilized e.g.by means of gamma irradiation as disclosed below for the kit (which isanother aspect of the present invention, see the section “Injectiondevice and kit”).

A particular embodiment of a manufacturing process according to theinvention is disclosed in detail in Example 1.

(PEG) Tipping the Needle:

In one embodiment, after the implant has been loaded into the needle thetip of the needle is dipped into a melted low-molecular weight PEG.Alternatively, molten PEG may be injected or placed/dripped into theneedle tip lumen. This low-molecular PEG is liquid (molten) at bodytemperature, but solid at room temperature. After applying the moltenPEG to the needle tip, either by dipping or dripping, upon cooling theneedle a hardened small drop or section (also referred to herein as“tip”) of PEG remains at and in the top of the needle which occludes theneedle lumen. The location of this tip/plug is shown in FIG. 25B.

The low-molecular weight PEG used in this embodiment may be a linear PEGand may have an average molecular weight of up to about 1500, or up toabout 1000, or may have an average molecular weight of about 400, about600, about 800 or about 1000. Also mixtures of PEGs of different averagemolecular weights as disclosed may be used. In specific embodiments theaverage molecular weight of the PEG used for this purpose of tipping theneedle is about 1000. This 1k (1000) molecular weight PEG has a meltingpoint between about 33° C. and about 40° C. and melts at bodytemperature when the needle is injected into the eye.

Alternatively to the PEG materials, any other material for tipping theinjection needle may be used that is water soluble and biocompatible(i.e., that may be used in contact with the human or animal body anddoes not elicit topical or systemic adverse effects, e.g. that is notirritating) and that is solid or hardened at room temperature but liquidor substantially liquid or at least soft at body temperature.Alternatively to PEG, also the following materials may e.g. be used(without being limited to these): poloxamers or poloxamer blends thatmelt/are liquid at body temperature; crystallized sugars or salts (suchas trehalose or sodium chloride), agarose, cellulose, polyvinyl alcohol,poly(lactic-co-glycolic acid), a UV-curing polymer, chitosan orcombinations of mixtures thereof.

The plug or tip aids in keeping the implant in place within the needleduring packaging, storage and shipping and also further protects theimplant from prematurely hydrating during handling as it occludes theneedle lumen. It also prevents premature rehydration of the implantwithin the needle due to moisture ingress during the administrationprocedure, i.e., during the time the physician prepares the needle andinjector for administration, and also at the time when the implant isabout to be injected and the needle punctures into the eye (as thepositive pressure in the eye could cause at least some prematurehydration of the implant just before it is actually injected). The tipor plug additionally provides lubricity when warmed to body temperatureand exposed to moisture and thereby allows successful deployment of theimplant. Moreover, by occluding the needle lumen, the needle tippingminimizes the potential for tissue injury, i.e., tissue coring, aprocess by which pieces of tissue are removed by a needle as it passesthrough the tissue.

In order to apply the PEG (or other material) tip/plug to the needlelumen, in one embodiment the needle containing the implant may bemanually or by means of an automated apparatus dipped into a containerof molten PEG (or the respective other material). The needle may be helddipped in the molten material for a few seconds to enable the moltenmaterial to flow upward into the needle through capillary action. Thedwell time, the dip depth and the temperature of the molten materialdetermine the final size or length of the tip/plug. In certainembodiments, the length of the PEG (or other) tip/plug at the top end ofthe needle may be from about 1 to about 5 mm, such as from about 2 toabout 4 mm. In certain embodiments, in case a 1k PEG is used the weightof the tip/plug may be from about 0.1 mg to about 0.6 mg, such as fromabout 0.15 mg to about 0.55 mg. It was demonstrated that implantsaccording to the present invention can be successfully deployed in vivoand in vitro from an injector carrying a needle with a 1k PEG tip asdisclosed herein.

The tipping of an injection needle as disclosed herein may also be usedfor the injection of other implants or other medicaments or vaccines tobe injected into the human or animal body (including other locationswithin the eye, or other areas or tissue of the body) by means of aneedle, where the effect of protection of the implant (or medicament orvaccine) from moisture and the protective effect on tissue into whichthe implant (or medicament or vaccine) is injected is desirable andadvantageous.

Stretching:

The shape memory effect of the stretching has already been disclosed indetail above with respect to the properties of the implant. In certainembodiments, the degree of shrinking upon hydration depends inter aliaon the stretch factor as already disclosed above.

In certain embodiments, the present invention thus also relates to amethod of imparting shape memory to a hydrogel strand comprising anactive agent dispersed in the hydrogel by stretching the hydrogel strandin the longitudinal direction.

Likewise, in certain embodiments, the present invention thus alsorelates to a method of manufacturing an ocular implant comprising ahydrogel comprising an active agent dispersed therein, wherein theimplant changes its dimensions upon administration to the eye, themethod comprising preparing a strand of the hydrogel and stretching itin the longitudinal direction.

Stretch factors for use in these methods of the invention may beutilized as already disclosed above. The described method of manufactureincluding the stretching methods are not limited to implants comprisingTKI inhibitors or axitinib, but may also be used for hydrogelscomprising other active pharmaceutical agents, or for implantscomprising hydrogels that are not formed from PEG units, but from otherpolymer units as disclosed herein above that are capable of forming ahydrogel.

In embodiments where the implant contains axitinib in an amount in arange from about 160 μg to about 250 μg, or in an amount of about 200μg, the stretching may be performed after drying the hydrogel by astretch factor of about 2 to about 5, or a stretch factor of about 3 toabout 4.5 (dry stretching).

In certain embodiments where the implant contains axitinib in an amountin a range from about 480 μg to about 750 μg, or in an amount of about600 μg, the stretching may be performed in a wet state prior to dryingthe hydrogel by a stretch factor of about 0.5 to about 5, or a stretchfactor of about 1 to about 4, or a stretch factor of about 1.3 to about3.5, or a stretch factor of about 1.7 to about 3, or a stretch factor ofabout 2.0 to 2.5 (wet stretching).

III. Injection Device and Kit

In certain embodiments, the present invention is further directed to akit (which may also be referred to as a “system”) comprising one or moresustained release biodegradable ocular implant(s) as disclosed above ormanufactured in accordance with the methods as disclosed above and oneor more needle(s) for injection, wherein the one or more needle(s)is/are each pre-loaded with one sustained release biodegradable ocularimplant in a dried state. In certain embodiments the needle(s) has agauge size of from 22 to 30, such as 22, 23, 24, 25, 26, 27, 28, 29, or30 gauge. In specific embodiments, the needles may be 25- or 27-gaugeneedle(s) or may be smaller gauge, such as 30-gauge needle(s). Thediameter of the needle is chosen based on the final diameter of theimplant in the dried (and optionally stretched) state. The activecontained in the implant is generally a TKI, such as axitinib.

In one embodiment the kit comprises one or more, such as two or three22- to 30-gauge, such as 25- or 27-gauge needle(s) each loaded with animplant containing axitinib in an amount in the range from about 180 μgto about 220 μg, or in an amount of about 200 μg.

In yet another embodiment the kit comprises one 25-gauge needle loadedwith an implant containing axitinib in an amount in the range from about540 μg to about 660 μg, or in an amount of about 600 μg. In anotherembodiment, the kit comprises one 27-gauge needle loaded with an implantcontaining axitinib in an amount in the range from about 540 μg to about660 μg, or in an amount of about 600 μg.

If two or more implants are contained in the kit, these implants may beidentical or different, and may contain identical or different doses ofTKI.

In certain embodiments, the lumen of the needle containing the implantmay be occluded by a material that is solid at room temperature but softor liquid at body temperature, such as a 1k PEG material, as disclosedherein in detail in the section “Manufacture of the Implant” andspecifically the subsection “(PEG) Tipping the needle” thereof.

The kit may further contain an injection device for injecting theimplant(s) into the eye of a patient, such as into the vitreous humor ofthe patient. In certain embodiments the injection device is providedand/or packaged separately from the one or more needle(s) loaded withimplant. In such embodiments the injection device must be connected tothe one or more needle(s) loaded with implant prior to injection.

In certain embodiments the number of injection devices providedseparately in the kit equals the number of needles loaded with theimplant provided in the kit. In these embodiments the injection devicesare only used once for injection of one implant.

In other embodiments the kit contains one or more injection device(s)for injecting the implant into the eye of a patient, such as into thevitreous humor of the patient, wherein each injection device is or isnot pre-connected to a needle loaded with implant. The present inventionthus in one aspect also relates to a pharmaceutical product comprising asustained release biodegradable ocular implant loaded in a needle and aninjection device, wherein the needle is pre-connected to the injectiondevice. In case the needle is not yet pre-connected to the injectiondevice, the physician administering the implant needs to remove both theneedle containing the implant and the injection device from thepackaging, and connect the needle to the injection device to be able toinject the implant into the patient's eye.

In some embodiments the injection device contains a push wire to deploythe implant from the needle into the vitreous humor. The push wire maybe a Nitinol push wire or may be a stainless steel/Teflon push wire. Thepush wire allows deploying the implant from the needle more easily.

In other embodiments the injection device and/or the injection needlemay contain a stop feature that controls the injection depth.

In some embodiments the injection device is or comprises a modifiedHamilton glass syringe that may be placed into a plastic syringehousing, such as inside an injection molded housing. A push wire, suchas a Nitinol wire, is inserted into the syringe and advances with theplunger of the syringe during deployment of the implant. To facilitateentry of the nitinol push wire into the needle, a hub insert may beadded into the needle hub. FIGS. 25A and 25B show one embodiment of aninjector according to the present invention for injecting an implantinto the vitreous humor of a patient. This depicted embodiment of aninjector comprises a Hamilton syringe body and a Nitinol push wire todeploy the implant. FIG. 25A shows the Hamilton syringe body inside ofan injection molded casing. FIG. 25B shows a schematic view of thecomponents of this embodiment of the injector. In certain embodiments,the injector comprising the Hamilton syringe body and the plastichousing parts are pre-assembled in a kit according to the invention andthe injector is ready for use (without or without mounted needlecontaining the implant). In other embodiments, the injector must beassembled by the physician prior to mounting the needle containing theimplant.

In other embodiments, the injection device is an injection moldedinjector. A schematic exploded view of an embodiment of such injectionmolded injector is shown in FIG. 26. In this case the number of assemblysteps by the physician just prior to administering the implant to apatient is reduced.

The kit may further comprise one or more doses, in particular one dose,of an anti-VEGF agent ready for injection. The anti-VEGF agent may beselected from the group consisting of aflibercept, bevacizumab,pegaptanib, ranibizumab, and brolucizumab. In certain embodiments theanti-VEGF agent is bevacizumab. In other embodiments the anti-VEGF agentis aflibercept. The anti-VEGF agent may be provided in a separateinjection device connected to a needle, or may be provided as a solutionor suspension in a sealed vial, from which the solution or suspensionmay be aspirated through a needle into a syringe or other injectiondevice prior to administration.

The kit may further comprise an operation manual for the physician whois injecting the ocular implant(s). The kit may further comprise apackage insert with product-related information.

In addition to the kit, the present invention in one aspect is alsodirected to an injection device per se that is suitable for injecting asustained release biodegradable ocular implant according to theinvention into the eye. The injection device may contain means forconnecting the injection device to a needle, wherein the needle ispre-loaded with the implant. The injection device may further contain apush wire to deploy the implant from the needle into the eye when theinjection device has been connected to the needle, which push wire maybe made of Nitinol or stainless steel/Teflon or another suitablematerial. The injection device may further be obtainable by affixing thewire to the plunger and encasing it between two snap fit injector bodyparts and securing the plunger with a clip. An injection device and aneedle pre-loaded with implant in accordance with certain embodiments ofthe present invention is depicted in FIG. 1.

As illustrated in FIG. 1, in some embodiments, the injection device(e.g., implant injector device) may include a first assembly and asecond assembly that are packaged separately (e.g., in separateenclosures). FIG. 26C is an exploded view of the first assembly and FIG.26D is an exploded view of the second assembly.

Referring to FIG. 26C, the first assembly includes a body forming afirst interior volume, a plunger including a first distal end disposedwithin the first interior volume, a wire including a first distal endsecured to the first distal end of the plunger, and a plunger clip. Theplunger clip is configured to interface with the plunger and the body toprevent actuation of the plunger. The body may include a first body halfand a second body half configured to interconnect with each other. Thebody may include a living hinge that interfaces with a protrusion of theplunger responsive to actuation of the plunger. The living hinge mayallow actuation of the plunger responsive to application of a thresholdforce.

Referring the FIG. 26D, the second assembly includes a cowl forming asecond interior volume, a needle including a base and a lumen, a cowlcap disposed within the base, and a needle shield configured to secureto the cowl and to be disposed around a portion of the lumen. An implantis configured to be disposed within the lumen of the needle. The cowlmay include a first cowl half and a second cowl half configured tointerconnect with each other. The second assembly may further include apolymer tip (e.g., PEG tip) disposed on a second distal end of thelumen. The implant is secured in the lumen between the cowl cap and thepolymer tip. The polymer tip is configured to liquefy (e.g., dissolve)within a user to allow the implant to be injected into the user.

In some embodiments, the second assembly is made from materials thatinclude less moisture and/or undergoes conditioning (e.g., nitrogenconditioning) prior to being sealed in an enclosure to prevent theimplant from absorbing moisture. In some embodiments, the first assemblyis made from materials that include more moisture and/or does notundergo conditioning prior to being sealed in an enclosure since theimplant is not included in the enclosure with the first assembly.

The first assembly may be removed from a first enclosure of FIG. 1 and asecond assembly may be removed from a second enclosure of FIG. 1.Referring to FIG. 26E, the first assembly and the second assembly may bealigned. One or more exterior recesses of the first assembly may alignwith one or more interior protrusions of the second assembly. The firstassembly and second assembly may include markings (e.g., arrows) toindicate how to align the first assembly and the second assembly.Referring to FIG. 26F, the cowl of the second assembly is secured to thebody of the first assembly (e.g., via the interior protrusions of thecowl entering the exterior recesses of the body). Referring to FIG. 26G,the needle shield is removed from the cowl of the second assembly andthe plunger clip is removed from the body and plunger of the firstassembly. Referring to FIG. 26H, the plunger of the first assembly isactuated (e.g., pushed into the body of the first assembly) to deploythe implant from the lumen of the needle of the second assembly. In someembodiments, the body has a living hinge that allows actuation of theplunger responsive to a threshold force being applied to the plunger. Insome embodiments, the lumen of the needle has a polymer tip (e.g., apolymer, such as PEG, disposed at least in the distal end of the lumen)blocking the implant from being deployed from the lumen. Insertion ofthe lumen with a polymer tip into a user may prevent coring of tissue ofthe user (e.g., cutting a piece of tissue the diameter of the inside ofthe lumen to later be deployed into the user). The lumen may be insertedin a user for a threshold amount of time (e.g., 1 to 5 seconds) toliquefy (e.g., dissolve) the polymer tip. After the polymer tip isliquefied, the implant may be deployed from the lumen via actuation ofthe plunger.

IV. Therapy

In certain embodiments, the present invention is further directed to amethod of treating an ocular disease in a patient in need thereof, themethod comprising administering to the patient the sustained releasebiodegradable ocular implant comprising the hydrogel and the tyrosinekinase inhibitor as disclosed above.

In specific embodiments, the present invention is directed to a methodof treating an ocular disease in a patient in need thereof, the methodcomprising administering to the patient a sustained releasebiodegradable ocular implant comprising a hydrogel and at least about150 μg of a tyrosine kinase inhibitor (TKI), wherein TKI particles aredispersed within the hydrogel.

In this treatment, the dose per eye administered once for a treatmentperiod of at least 3 months is at least about 150 μg, such as from about150 μg to about 1800 μg, or from about 150 μg to about 1200 μg of thetyrosine kinase inhibitor. In certain preferred embodiments the tyrosinekinase inhibitor is axitinib.

In certain embodiments the dose of the TKI, and specifically ofaxitinib, administered per eye once for (i.e., during) the treatmentperiod is in the range of about 200 μg to about 800 μg. In certainembodiments the dose is in the range from about 160 μg to about 250 μg,or from about 180 μg to about 220 μg, or of about 200 μg.

In yet other specific embodiments this dose is in the range from about320 μg to about 500 μg, or from about 360 μg to about 440 μg, or ofabout 400 μg. In yet other embodiments this dose is in the range fromabout 480 μg to about 750 μg, or from about 540 μg to about 660 μg, orof about 600 μg. In yet other embodiments this dose is in the range fromabout 640 μg to about 1000 μg, or from about 720 μg to about 880 μg, orof about 800 μg. In yet other embodiments this dose is in the range fromabout 800 μg to about 1250 μg, or from about 900 μg to about 1100 μg, orof about 1000 μg. In yet other embodiments this dose is in range fromabout 960 μg to about 1500 μg, or from about 1080 μg to about 1320 μg,or of about 1200 μg. In particular embodiments, the dose administeredper eye once for the treatment period is about 600 μg axitinib. Inparticular embodiments, this dose of 600 μg is contained in one singleimplant.

In certain embodiments, the treatment period for the treatment of anocular disease as disclosed herein with an implant of the presentinvention is least 3 months, at least 4.5 months, at least 6 months, atleast 9 months, at least 11 months, at least 12 months, at least 13months, at least 14 months or even longer, and may for example be about6 to about 9 months.

In certain embodiments the ocular disease involves angiogenesis.

In other embodiments the ocular disease may be mediated by one or morereceptor tyrosine kinases (RTKs), such as VEGFR-1, VEGFR-2, VEGFR-3,PDGFR-α/β, and/or by c-Kit.

In some embodiments the ocular disease is a retinal disease includingChoroidal Neovascularization, Diabetic Retinopathy, Diabetic MaculaEdema, Retinal Vein Occlusion, Acute Macular Neuroretinopathy, CentralSerous Chorioretinopathy, and Cystoid Macular Edema; wherein the oculardisease is Acute Multifocal Placoid Pigment Epitheliopathy, Behcet'sDisease, Birdshot Retinochoroidopathy, Infectious (Syphilis, Lyme,Tuberculosis, Toxoplasmosis), Intermediate Uveitis (Pars Planitis),Multifocal Choroiditis, Multiple Evanescent White Dot Syndrome (MEWDS),Ocular Sarcoidosis, Posterior Scleritis, Serpignous Choroiditis,Subretinal Fibrosis, Uveitis Syndrome, or Vogt-Koyanagi-Harada Syndrome;wherein the ocular disease is a vascular disease or exudative diseases,including Coat's Disease, Parafoveal Telangiectasis, Papillophlebitis,Frosted Branch Angitis, Sickle Cell Retinopathy and otherHemoglobinopathies, Angioid Streaks, and Familial ExudativeVitreoretinopathy; or wherein the ocular disease results from trauma orsurgery, including Sympathetic Ophthalmia, Uveitic Retinal Disease,Retinal Detachment, Trauma, Photodynamic Laser Treatment,Photocoagulation, Hypoperfusion During Surgery, Radiation Retinopathy,or Bone Marrow Transplant Retinopathy.

In alternative embodiments the sustained release biodegradable ocularimplant comprising the hydrogel and the tyrosine kinase inhibitor of thepresent invention can be applied in treating ocular conditionsassociated with tumors. Such conditions include e.g., Retinal DiseaseAssociated with Tumors, Solid Tumors, Tumor Metastasis, Benign Tumors,for example, hemangiomas, neurofibromas, trachomas, and pyogenicgranulomas, Congenital Hypertrophy of the RPE, Posterior Uveal Melanoma,Choroidal Hemangioma, Choroidal Osteoma, Choroidal Metastasis, CombinedHamartoma of the Retina and Retinal Pigmented Epithelium,Retinoblastoma, Vasoproliferative Tumors of the Ocular Fundus, RetinalAstrocytoma, or Intraocular Lymphoid Tumors.

In general, the ocular implants of the present invention can also beapplied for treatment of any ocular disease involving vascular leakage.

In certain embodiments the ocular disease is one selected from the listconsisting of neovascular age-related macular degeneration (AMD),diabetic macula edema (DME), and retinal vein occlusion (RVO). Inparticular embodiments the ocular disease is neovascular age-relatedmacular degeneration.

In some embodiments the treatment is effective in reducing the centralsubfield thickness (CSFT) as measured by optical coherence tomography ina patient whose central subfield thickness is elevated. Elevated withinthat context means that the CSFT is higher in the patient when comparedto other individuals not suffering from the specific ocular disease. Theelevated CSFT may be caused by retinal fluid such as sub- orintraretinal fluid. The reduction of CSFT in a patient may be determinedwith respect to a baseline CSFT measured in that patient prior to thestart of the treatment, i.e., prior to the administration of the implantof the present invention. The capacity of the implants of the presentinvention to reduce CSFT and to maintain or to substantially maintain areduced CSFT over an extended period of time in a cohort of patients isdemonstrated in Example 6.3 and 6.4. In other embodiments, by means ofthe treatment according to the present invention involving theadministration of an implant according to the present invention the CSFTof a patient whose CSFT is elevated due to an ocular disease involvingangiogenesis is essentially maintained at a certain given level, or aclinically significant increase of the CSFT is prevented in the patientwhile sub- or intraretinal fluid is not substantially increased, i.e.,is also essentially maintained.

In a particular embodiment, the CSFT is reduced in a patient andmaintained at a reduced level over a period of at least 3 months, atleast 4.5 months, at least 6 months, at least 9 months, at least 11months, at least 12 months, at least 13 months, at least 14 months oreven longer after administration of the implant of the invention. In avery particular embodiment, the CSFT is reduced for at least 6 months orat least 9 months or at least 12 months after administration of theimplant with respect to the baseline CSFT of that patient prior toadministration of the implant. In other particular embodiments, areduced amount of retinal fluid and/or a reduced CSFT is maintained in apatient over a treatment period of at least 3 months, at least 4.5months, at least 6 months, at least 9 months, at least 11 months, atleast 12 months, at least 13 months, at least 14 months or even longerafter administration of the implant of the invention without the needfor administration of rescue medication (such as an injection of ananti-VEGF agent), or wherein rescue medication is administered onlyrarely, such as 1, 2, or 3 times during the treatment period. Thus, inthis embodiment, during the treatment period with an implant accordingto the present invention the patient receiving the treatment may notneed any rescue medication, or the administration of rescue medicationis only required rarely, such as 1, 2 or 3 times during the treatmentperiod.

In certain embodiments, the rescue medication is an anti-VEGF agent,such as aflibercept or bevacizumab, that is administered in the form ofa suspension or solution by means of intravitreal injection. In certainspecific embodiments, the rescue medication is one dose (2 mg) ofaflibercept, administered by means of intravitreal injection. In linewith the definitions herein, concurrent (i.e., planned) administrationof an anti-VEGF agent together with an implant according to anotherembodiment of the present invention disclosed herein does not constitutea “rescue medication”. In more particular embodiments, the treatmentperiod wherein the level of fluid and/or the CSFT (as reduced by meansof the administration of an implant according to the invention) ismaintained or essentially maintained without the administration ofrescue medication (or with rescue medication administered only rarely)is from about 6 to about 9 months after administration of the implant.In certain embodiments, the patients treated with an implant accordingto the invention do not require the concomitant administration ofsteroids (e.g., dexamethasone or prednisolone drops) during thetreatment period.

In another embodiment, by means of the treatment according to thepresent invention involving the administration of an implant accordingto the present invention the CSFT of a patient whose CSFT is elevateddue to angiogenesis is reduced, essentially maintained, or a clinicallysignificant increase of the CSFT is prevented while the patient's vision(e.g. expressed by means of the best corrected visual acuity, alsoreferred to herein as “BCVA”) is not impaired, or is not significantlyimpaired. In certain embodiments, by means of the treatment according tothe present invention involving the administration of an implantaccording to the present invention a patient's vision (where thepatient's vision is impaired due to an ocular disease involvingangiogenesis) as e.g. expressed by the BCVA may improve during thetreatment period of at least 3 months, at least 6 months, at least 9months, at least 11 months, at least 12 months, at least 13 months or atleast 14 months.

Thus, in certain embodiments the present invention provides a method ofimproving the vision of a patient whose vision is impaired e.g. due toretinal fluid caused by an ocular disease involving angiogenesis,wherein the method comprises administering an implant according to theinvention to the patient, such as by means of intravitreal injection.The improvement of the vision of a patient may be assessed for instanceby means of the BCVA. An improvement of vision may manifest itself by anincrease of the patient's BCVA e.g. by at least 10, or at least 15, orat least 20 ETDRS letters.

In certain embodiments, the total dose of TKI, such as axitinib, per eyeadministered once for the treatment period may be contained in one ormore implants. In certain embodiments the dose per eye administered oncefor the treatment period is contained in one implant as for instance inone implant comprising a dose of about 600 μg or of about 200 μgaxitinib. In other embodiments the total dose per eye administered oncefor the treatment period is contained in e.g. two implants, wherein eachimplant comprises a dose of e.g. about 200 μg axitinib (resulting in atotal dose of about 400 μg in that case). In yet other embodiments thedose per eye administered once for the treatment period is contained ine.g. three implants, wherein each implant comprises a dose of e.g. about200 μg axitinib (resulting in a total dose of about 600 μg in thatcase). In particular embodiments of the methods of treatment of thepresent invention, the dose of axitinib administered to one eye is about600 μg and is contained in one implant.

For the injection of implants according to the present invention intothe eye, such as into the vitreous humor, of a patient in the course ofa treatment of an ocular disease, such as a retinal disease, includingAMD, it is generally desirable to use implants having a therapeuticallyeffective dose of TKI (i.e., one that is appropriate in view ofparticular patient's type and severity of condition) in a relativelysmall implant in order to facilitate administration (injection) as wellas to reduce possible damage to ocular tissue as well as a possibleimpact of the patient's vision while the implant is in place. Theimplants of the present invention advantageously combine the benefits ofa suitably high dose of the TKI (i.e., a therapeutically effective doseadjusted to a particular patient's need) with a relatively small implantsize.

In certain embodiments, the implant may be administered by means of aninjection device according to the present invention connected to aneedle pre-loaded with implant as disclosed herein, or may beadministered by means of another injection device suitable to beconnected to a needle pre-loaded with an implant as disclosed herein,such as a (modified) Hamilton syringe. In other embodiments, a hollowmicroneedle may be used for suprachoroidal administration as disclosedin U.S. Pat. No. 8,808,225 which is incorporated by reference herein.

In embodiments wherein two or more implants are administered, theimplants are generally administered concurrently as disclosed hereinabove. The implants administered concurrently can be the same ordifferent. In cases where an administration during the same session isnot possible e.g. due to administration complications or patient-relatedreasons a successive administration during two or more differentsessions may alternatively be applied, such as for instanceadministration of two implants 7 days apart. This may still beconsidered as a “concurrent” administration in the context of thepresent invention.

In certain embodiments the dry implants are loaded in a needle, such asa needle with a gauge size of from 22 to 23, such as a 25-gauge or a27-gauge needle, or a smaller gauge needle, for injection and areadministered to the eye, e.g. to the vitreous humor, through thisneedle. In one embodiment, the injector used for injecting the implantinto the eye is an injection device according to another aspect of thepresent invention as disclosed above. Implants containing 200 μg and 600μg, respectively, that are suitable for the therapeutic applicationsaccording to the present application are exemplarily presented in Tables21.1 and 21.2.

The implant can generally be administered by means of intravitreal,subconjunctival, subtenon, suprachoroidal, or intracameral injection. Incertain embodiments the implant is administered to the vitreous humor,e.g. the implant is administered intravitreally into the posteriorsection of the vitreous humor. In other embodiments, the implant isadministered by means of a hollow microneedle, such as into the scleraof the eye at an insertion site into the suprachoroidal space of the eyeas disclosed in U.S. Pat. No. 8,808,225, which is incorporated herein byreference.

In certain embodiments, the treatment period is at least 3 months, butmay be at least 4.5 months, at least 6 months, at least 9 months, atleast 11 months or at least 12 months. In particular embodiments, thetreatment period is at least 6 months, at least 9 months, at least 11months, at least 12 months, at least 13 months, or at least 14 months.In certain embodiments, the treatment period may also be longer, such asup to about 15 months. “Treatment period” according to one embodiment ofthe invention means that a certain therapeutic effect of an implant ofthe present invention once administered is maintained, essentiallymaintained or partially maintained over that period of time. In otherwords, only one injection (of the implant of the present invention) isrequired in certain embodiments for maintaining a therapeutic effect ofreducing or essentially maintaining or of preventing a clinicallysignificant increase of the CSFT during the extended period of timereferred to herein as “treatment period”. This is a considerableadvantage over currently used anti-VEGF treatments for AMD which requiremore frequent administration, and thus improves the patient's quality oflife. Another advantage is that the necessity and/or frequency of theadministration of rescue medication during the treatment period is verylow. In certain embodiments, no rescue medication is necessary duringthe treatment period, such as a treatment period of from about 6 toabout 9 months after administration of the implant. In certain otherembodiments, rescue medication only has to be administered rarely, suchas 1, 2 or 3 times during the treatment period. The vision of a patientmay be improved as evidenced e.g. by an increase in the BCVA (such as byat least 10, at least 15 or at least 20 ETDRS letters) followingadministration of an implant of the invention.

In one particular embodiment the invention is directed to a method oftreating neovascular age-related macular degeneration in a patient inneed thereof, the method comprising administering to the patient asustained release biodegradable ocular implant comprising a hydrogelthat comprises a polymer network and about 200 μg of a tyrosine kinaseinhibitor, wherein one implant per eye is administered once for atreatment period of at least 9 months, and wherein the patient has ahistory of an anti-VEGF treatment. In this embodiment the treatmentresults in a reduction in central subfield thickness (CSFT), or at leastmaintenance of CSFT, as measured by optical coherence tomography duringthe treatment period. In this embodiment the TKI may further beaxitinib, which is dispersed in the hydrogel which comprises a polymernetwork formed by reacting 4a20kPEG-SAZ with 8a20kPEG-NH₂, and whereinthe implant is in a dried state prior to administration. In thisembodiment the hydrogel when formed and before being dried containsabout 7.5% polyethylene glycol, representing the polyethylene glycolweight divided by the fluid weight×100. Alternatively, the patienttreated may also have no history of an anti-VEGF treatment (AMDtreatment naïve).

In another particular embodiment the invention is directed to a methodof treating neovascular age-related macular degeneration in a patient inneed thereof, the method comprising administering to the patient asustained release biodegradable ocular implant comprising a hydrogelthat comprises a polymer network and about 200 μg of a tyrosine kinaseinhibitor, wherein two implants per eye forming a total dose of about400 μg are administered once for a treatment period of at least 3months, or for at least 9 months, and wherein the patient has a historyof an anti-VEGF treatment or has no history of an anti-VEGF treatment(AMD treatment naïve). In this embodiment the treatment results in areduction (or at least maintenance of) central subfield thickness (CSFT)as measured by optical coherence tomography during the treatment period.In this embodiment the TKI may further be axitinib which is dispersed inthe hydrogel which comprises a polymer network formed by reacting4a20kPEG-SAZ with 8a20kPEG-NH₂, and wherein the implant is in a driedstate prior to administration. In this embodiment the hydrogel whenformed and before being dried contains about 7.5% polyethylene glycol,representing the polyethylene glycol weight divided by the fluidweight×100.

In yet another particular embodiment the invention is directed to amethod of treating neovascular age-related macular degeneration in apatient in need thereof, the method comprising administering to thepatient a sustained release biodegradable ocular implant comprising ahydrogel that comprises a polymer network and about 200 μg of a tyrosinekinase inhibitor, wherein three implants per eye forming a total dose ofabout 600 μg are administered once for a treatment period of at least 3months, or for at least 9 months, and wherein the patient has a historyof an anti-VEGF treatment or has no history of an anti-VEGF treatment(AMD treatment naïve). In this embodiment the treatment results in areduction (or at least maintenance of) central subfield thickness (CSFT)as measured by optical coherence tomography during the treatment period.In this embodiments the TKI may further be axitinib which is dispersedin the hydrogel which comprises a polymer network formed by reacting4a20kPEG-SAZ with 8a20kPEG-NH₂, and wherein the implant is in a driedstate prior to administration. In this embodiment the hydrogel whenformed and before being dried contains about 7.5% polyethylene glycol,representing the polyethylene glycol weight divided by the fluidweight×100.

In yet other embodiments the invention is directed to a method oftreating neovascular age-related macular degeneration in a patient inneed thereof, the method comprising administering to the patient asustained release biodegradable ocular implant comprising axitinib in anamount in the range from about 480 μg to about 750 μg dispersed in ahydrogel comprising a polymer network, wherein the implant isadministered once for a treatment period of at least 3 months. Incertain of these embodiments the axitinib is contained in the implant inan amount of from about 560 μg to about 660 μg, or of about 600 μg. Forspecific properties of the implant reference is made to the sectionsabove directed to an implant according to the present inventioncontaining axitinib in an amount in the range from about 480 μg to about750 μg, or in an amount from about 560 μg to about 660 μg, or of about600 μg. The implant may be administered into the vitreous humor, e.g. bymeans of a fine diameter, such as a 25-gauge, needle. The treatmentperiod as defined above may be at least 4.5 months, or at least 6months, or at least 9 months, or at least 11 months, or at least 12months, or at least 13 months, or at least 14 months or even longer,such as up to about 15 months. In particular embodiments, the treatmentperiod is at least 6 months, or at least 9 months, or at least 12months, or from about 6 to about 9 months.

In some embodiments concurrently with the treatment with the sustainedrelease biodegradable ocular implant(s) containing a TKI, or a treatmentwith the sustained release biodegradable ocular implant(s) containingaxitinib according to the invention, an anti-VEGF agent is administeredto the patient. The anti-VEGF agent may be selected from the groupconsisting of aflibercept, bevacizumab, pegaptanib, ranibizumab, andbrolucizumab. In certain embodiments the anti-VEGF agent is bevacizumab.In particular embodiments the anti-VEGF agent is aflibercept. In certainembodiments the anti-VEGF agent is administered by means of anintravitreal injection concurrently (as defined above) with theadministration of the sustained release biodegradable ocular implant,optionally at the same time, i.e., in one session as already disclosedabove in detail. In cases where an administration of the anti-VEGF agentand the implant of the present invention may not be possible in the samesession, e.g. due to administration complications or patient-relatedreasons a successive administration during two or more differentsessions may alternatively be applied, such as for instanceadministration of two implants 7 days apart. This may still beconsidered as a “concurrent” administration in the context of thepresent invention.

In other embodiments, an anti-VEGF agent may be administered incombination with an implant of the present invention, but not at thesame time (i.e., not concurrently), but at an earlier or a later pointduring the treatment period of the implant of the present invention. Incertain embodiments, an anti-VEGF agent may be administered within about1, about 2, or about 3, or more months of the administration of theimplant, i.e., may be pre- or post-administered as compared to theimplant. This combined (and planned) co-administration of an anti-VEGFagent differs from a rescue medication as defined herein.

In certain embodiments of the present invention the patient has adiagnosis of primary subfoveal (such as active sub- or juxtafoveal CNVwith leakage involving the fovea) neovascularization (SFNV) secondary toAMD.

In certain embodiments of the present invention the patient has adiagnosis of previously treated subfoveal neovascularization (SFNV)secondary to neovascular AMD with leakage involving the fovea. In suchpatient, the previous treatment was with an anti-VEGF agent.

In some embodiments the patient is at least 50 or at least 60 years old.The patient may be male or female. The patient may have retinal fluidsuch as intra-retinal fluid or sub-retinal fluid.

In some embodiments the patient receiving the implant has a history ofan anti-VEGF treatment e.g. such as treatment with LUCENTIS® and/orEYLEA®. In certain embodiments the patient receiving the implant has ahistory of anti-VEGF treatment but has not responded to this anti-VEGFtreatment, i.e. the disease state of the patient was not improved by theanti-VEGF treatment. In embodiments where the patient has a history ofan anti-VEGF treatment before starting the treatment with the implantaccording to the present invention, administration of the implant of thepresent invention may prolong the effect of the prior anti-VEGFtreatment over an extended period of time, such as over the treatmentperiod defined above. In other embodiments the patient receiving theimplant has no history of an anti-VEGF treatment (anti-VEGF naïve, AMDtreatment naïve).

In certain embodiments the systemic plasma concentration of the TKI suchas axitinib is below 1 ng/mL, or below 0.5 ng/ml, or below 0.3 ng/mL, orbelow 0.1 ng/mL (or below the limit of quantification). As systemicconcentrations of TKI are kept at a minimum, the risk of drug-to-druginteractions or systemic toxicity is also kept at a minimum. Therefore,in one embodiment additional medication(s) taken by the patients do notprovide a significant risk. This is especially beneficial in olderpatients who are frequently suffering from ocular diseases and areadditionally taking other medications.

Once injected the implants of certain embodiments of the invention(comprising the hydrogel and the drug) biodegrade within an extendedperiod of time as disclosed above, e.g., about 9 to 12 months. Incertain embodiments it may be that once the hydrogel is fully degradedundissolved axitinib particles remain localized at the site where theimplant was located. These undissolved particles may further maintain arate of TKI delivery sufficient for therapeutic effect (i.e. inhibitionof vascular leakage) when the hydrogel is degraded. FIG. 15 exemplarilypresents the resorption of the hydrogel and remaining axitinib particlesat the former implant location in one patient until 11 months afteradministration. In certain embodiments, however, the entire amount ofTKI is dissolved prior to complete degradation of the hydrogel.

In certain embodiments only mild or moderate adverse events such asocular adverse events are observed over the treatment period. In certainembodiments no serious ocular adverse are observed, and notreatment-related serious ocular adverse events are observed. Tables 23and 25 show the occurrence of adverse events in the cohort 1 and 2, aswell as the cohort 3a and 3b subjects, respectively, of the clinicalstudy the results of which (as far as available) are presented inExample 6.4.

The invention in certain embodiments is further directed to a method ofreducing, essentially maintaining or preventing a clinically significantincrease of the central subfield thickness as measured by opticalcoherence tomography in a patient whose central subfield thickness iselevated due to an ocular disease involving angiogenesis, the methodcomprising administering to the patient the sustained releasebiodegradable ocular implant containing a tyrosine kinase inhibitor ofthe present invention as disclosed herein. In certain embodiments theocular disease involving angiogenesis is neovascular age-related maculardegeneration. In other embodiments the central subfield thickness isreduced, essentially maintained or a clinically significant increase ofthe central subfield thickness is prevented during a period of at least3 months, at least 4.5 months, at least 6 months, at least 9 months, atleast 11 months, at least 12 months, at least 13 months, or at least 14months or even longer, such as at least 15 months after administrationto the patient whose central subfield thickness is elevated due to anocular disease involving angiogenesis, such as neovascular age-relatedmacular degeneration. In certain embodiments, the patient's visionexpressed e.g. by the BCVA is not substantially impaired during thetreatment. In certain other embodiments, the patient's vision expressede.g. by the BCVA may even be improved. Accordingly, the invention incertain embodiments is also directed to a method of improving the visionof a patient whose vision is impaired e.g. due to retinal fluid causedby an ocular disease involving angiogenesis, wherein the methodcomprises administering an implant according to the invention to thepatient, such as by means of intravitreal injection.

Additional Disclosure

In addition to the disclosure above, the present invention alsodiscloses the following items and lists of items:

First List of Items

-   -   1. A sustained release biodegradable ocular implant comprising a        hydrogel and about 150 μg to about 1200 μg of a tyrosine kinase        inhibitor.    -   2. The sustained release biodegradable ocular implant of item 1,        wherein the tyrosine kinase inhibitor is axitinib.    -   3. The sustained release biodegradable ocular implant of claim 1        or 2, comprising the tyrosine kinase inhibitor in an amount in        the range from about 200 μg to about 800 μg.    -   4. The sustained release biodegradable ocular implant of item 1        or 2, comprising the tyrosine kinase inhibitor in an amount in        the range from about 160 μg to about 250 μg.    -   5. The sustained release biodegradable ocular implant of claim        4, comprising the tyrosine kinase inhibitor in an amount in the        range from about 180 μg to about 220 μg.    -   6. The sustained release biodegradable ocular implant of item 5,        comprising the tyrosine kinase inhibitor in an amount of about        200 μg.    -   7. The sustained release biodegradable ocular implant of claim 1        or 2, comprising the tyrosine kinase inhibitor in an amount in        the range from about 320 μg to about 500 μg.    -   8. The sustained release biodegradable ocular implant of item 7,        comprising the tyrosine kinase inhibitor in an amount in the        range from about 360 μg to about 440 μg.    -   9. The sustained release biodegradable ocular implant of claim        8, comprising the tyrosine kinase inhibitor in an amount of        about 400 μg.    -   10. The sustained release biodegradable ocular implant of item 1        or 2, comprising the tyrosine kinase inhibitor in an amount in        the range from about 480 μg to about 750 μg.    -   11. The sustained release biodegradable ocular implant of claim        10, comprising the tyrosine kinase inhibitor in an amount from        about 540 μg to about 660 μg.    -   12. The sustained release biodegradable ocular implant of item        11, comprising the tyrosine kinase inhibitor in an amount of        about 600 μg.    -   13. The sustained release biodegradable ocular implant of item 1        or 2, comprising the tyrosine kinase inhibitor in an amount in        the range from about 640 μg to about 1000 μg.    -   14. The sustained release biodegradable ocular implant of item        13, comprising the tyrosine kinase inhibitor in an amount from        about 720 μg to about 880 μg.    -   15. The sustained release biodegradable ocular implant of item        14, comprising the tyrosine kinase inhibitor in an amount of        about 800 μg.    -   16. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant is for administration        into the posterior section of the eye.    -   17. The sustained release biodegradable ocular implant of item        16, wherein the administration is into the vitreous humor.    -   18. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the tyrosine kinase inhibitor        particles are dispersed within the hydrogel.    -   19. The sustained release biodegradable ocular implant of item        18, wherein the tyrosine kinase inhibitor particles are        micronized particles.    -   20. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant is in a dried state        prior to administration and becomes hydrated once administered        into the eye.    -   21. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the hydrogel comprises a polymer        network comprising one or more units of polyethylene glycol,        polyethylene oxide, polypropylene oxide, polyvinyl alcohol, poly        (vinylpyrrolidinone), polylactic acid, polylactic-co-glycolic        acid, random or block copolymers or combinations or mixtures of        any of these, or one or more units of polyaminoacids,        glycosaminoglycans, polysaccharides, or proteins.    -   22. The sustained release biodegradable ocular implant of item        21, wherein the hydrogel comprises a polymer network that        comprises crosslinked polymer units that are identical or        different.    -   23. The sustained release biodegradable ocular implant of item        22, wherein crosslinked polymer units are one or more        crosslinked polyethylene glycol units.    -   24. The sustained release biodegradable ocular implant of any of        items 21 to 23, wherein the polymer network comprises        polyethylene glycol units having an average molecular weight in        the range from about 2,000 to about 100,000 Daltons.    -   25. The sustained release biodegradable ocular implant of item        24, wherein the polyethylene glycol units have an average        molecular weight in the range from about 10,000 to about 60,000        Daltons.    -   26. The sustained release biodegradable ocular implant of item        25, wherein the polyethylene glycol units have an average        molecular weight in the range from about 20,000 to about 40,000        Daltons.    -   27. The sustained release biodegradable ocular implant of item        26, wherein the polyethylene glycol units have an average        molecular weight of about 20,000 Daltons.    -   28. The sustained release biodegradable ocular implant of any of        items 21 to 27, wherein the polymer network comprises one or        more crosslinked multi-arm polymer units.    -   29. The sustained release biodegradable ocular implant of item        28, wherein the multi-arm polymer units comprise one or more 2-        to 10-arm polyethylene glycol units.    -   30. The sustained release biodegradable ocular implant of item        29, wherein the multi-arm polymer units comprise one or more 4-        to 8-arm polyethylene glycol units.    -   31. The sustained release biodegradable ocular implant of item        30, wherein the multi-arm polymer units comprise one or more        4-arm polyethylene glycol units.    -   32. The sustained release biodegradable ocular implant of any of        items 21 to 31, wherein the polymer network comprises both 4-arm        and 8-arm polyethylene glycol units.    -   33. The sustained release biodegradable ocular implant of any of        items 21 to 32, wherein the polymer network is formed by        reacting an electrophilic group-containing multi-arm-polymer        precursor with a nucleophilic group-containing multi-arm polymer        precursor.    -   34. The sustained release biodegradable ocular implant of any of        items 21 to 33, wherein the nucleophilic group is an amine        group.    -   35. The sustained release biodegradable ocular implant of any of        items 21 to 34, wherein the electrophilic group is an activated        ester group.    -   36. The sustained release biodegradable ocular implant of item        35, wherein the electrophilic group is an N-hydroxysuccinimidyl        (NHS) group.    -   37. The sustained release biodegradable ocular implant of item        36, wherein the electrophilic group is a succinimidylazelate        (SAZ) group.    -   38. The sustained release biodegradable ocular implant of any of        items 32 to 37, wherein the 4-arm polyethylene glycol units are        4a20kPEG units and the 8-arm polyethylene glycol units are        8a20kPEG units.    -   39. The sustained release biodegradable ocular implant of item        38, wherein the polymer network is obtained by reacting        4a20kPEG-SAZ with 8a20kPEG-NH₂ in a weight ratio of about 2:1 or        less.    -   40. The sustained release biodegradable ocular implant of any of        items 1 to 39, wherein the implant in a dried state contains        from about 25% to about 75% by weight of the tyrosine kinase        inhibitor and from about 20% to about 60% by weight polymer        units.    -   41. The sustained release biodegradable ocular implant of item        40, wherein the implant in a dried state contains from about 35%        to about 65% by weight of the tyrosine kinase inhibitor and from        about 25% to about 50% by weight polymer units.    -   42. The sustained release biodegradable ocular implant of item        41, wherein the implant in a dried state contains from about 45%        to about 55% by weight of the tyrosine kinase inhibitor and from        about 37% to about 47% by weight polymer units.    -   43. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant contains one or more        phosphate, borate or carbonate salt(s).    -   44. The sustained release biodegradable ocular implant of item        43, wherein the implant contains phosphate salt originating from        phosphate buffer used during the preparation of the hydrogel.    -   45. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the hydrogel in a wet state        contains about 3% to about 20% polyethylene glycol representing        the polyethylene glycol weight divided by the fluid weight×100.    -   46. The sustained release biodegradable ocular implant of item        45, wherein the hydrogel contains about 7.5% to about 15%        polyethylene glycol representing the polyethylene glycol weight        divided by the fluid weight×100.    -   47. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant in a dried state        contains not more than about 1% by weight water.    -   48. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant has an essentially        cylindrical shape or another shape such as a cross shape.    -   49. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant is in the form of a        fiber.    -   50. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant is administered to the        eye through a needle.    -   51. The sustained release biodegradable ocular implant of item        50, wherein the needle is a 25- or 27-gauge needle.    -   52. The sustained release biodegradable ocular implant of any of        the preceding items, wherein upon hydration in vivo in the eye        or in vitro the diameter of the implant is increased, or the        length of the implant is decreased while its diameter is        increased.    -   53. The sustained release biodegradable ocular implant of item        52, wherein hydration is measured in vitro in phosphate-buffered        saline at a pH of 7.2 at 37° C. after 24 hours.    -   54. The sustained release biodegradable ocular implant of any of        items 17 to 53, wherein the implant biodegrades in the vitreous        humor within about 2 to about 15 months after administration.    -   55. The sustained release biodegradable ocular implant of item        54, wherein the implant biodegrades in the vitreous humor within        about 4 to about 13 months after administration.    -   56. The sustained release biodegradable ocular implant of item        55, wherein the implant biodegrades in the vitreous humor within        about 9 to about 12 months after administration.    -   57. The sustained release biodegradable ocular implant of any of        items 2 to 56, wherein the implant after administration to the        vitreous humor releases a therapeutically effective amount of        axitinib over a period of at least about 3 months, at least        about 6 months, at least about 9 months, at least about 10        months, at least about 11 months, at least about 12 months, at        least about 13 months, or at least about 14 months after        administration.    -   58. The sustained release biodegradable ocular implant of item        57, wherein the implant after administration to the vitreous        humor releases a therapeutically effective amount of axitinib        over a period of at least about 6 months.    -   59. The sustained release biodegradable ocular implant of item        57, wherein the implant after administration to the vitreous        humor releases a therapeutically effective amount of axitinib        over a period of at least about 9 months.    -   60. The sustained release biodegradable ocular implant of any of        items 17 to 59, wherein axitinib is released from the implant        after administration at an average rate of about 0.1 μg/day to        about 10 μg/day.    -   61. The sustained release biodegradable ocular implant of item        60, wherein axitinib is released from the implant at an average        rate of about 0.5 μg/day to about 7 μg/day.    -   62. The sustained release biodegradable ocular implant of item        61, wherein axitinib is released from the implant at an average        rate about 1 μg/day to about 5 μg/day.    -   63. The sustained release biodegradable ocular implant of any of        items 17 to 62, wherein the implant biodegrades in the vitreous        humor prior to complete solubilization of the tyrosine kinase        inhibitor particles contained in the implant.    -   64. The sustained release biodegradable ocular implant of any of        items 17 to 63, wherein the entire amount of the tyrosine kinase        inhibitor contained in the implant is released prior to the        complete degradation of the implant in the vitreous humor.    -   65. The sustained release biodegradable ocular implant of any of        the preceding items, wherein the implant is obtainable by        preparing a mixture containing hydrogel precursors and a        tyrosine kinase inhibitor, filling the mixture into a tubing,        allowing the hydrogel to gel in the tubing to provide a hydrogel        shaped as a fiber, and stretching the hydrogel fiber.    -   66. The sustained release biodegradable ocular implant of item        65, wherein the fiber has been stretched and/or twisted prior to        or after drying.    -   67. The sustained release biodegradable ocular implant of item        66, wherein the fiber has been stretched by a stretch factor in        the longitudinal direction of from about 1.0 to about 4.5.    -   68. A sustained release biodegradable ocular implant containing        axitinib in an amount of 160 μg to about 250 μg, or from about        180 μg to about 220 μg, or about 200 μg dispersed in a hydrogel,        wherein the hydrogel comprises a polymer network comprising        polyethylene glycol units, and wherein the implant is in a dried        state prior to administration.    -   69. The sustained release biodegradable ocular implant of item        68, wherein the polymer network is formed by reacting        4a20kPEG-SAZ with 8a20kPEG-NH₂.    -   70. The sustained release biodegradable ocular implant of item        69, wherein the hydrogel when formed and before being dried        contains 7.5% polyethylene glycol, representing the polyethylene        glycol weight divided by the fluid weight×100.    -   71. The sustained release biodegradable ocular implant of any of        items 68 to 70, wherein the implant in a dried state contains        from about 45% to about 55% by weight axitinib and from about        37% to about 47% by weight polyethylene glycol units.    -   72. The sustained release biodegradable ocular implant of any of        items 68 to 71, wherein the implant in a dried state contains        not more than about 1% by weight water.    -   73. The sustained release biodegradable ocular implant of any of        items 68 to 72, wherein the polymer network is formed by        reacting 4a20kPEG-SAZ with 8a20kPEG-NH₂ in a weight ratio of        about 2:1 or less.    -   74. The sustained release biodegradable ocular implant of any of        items 68 to 73, wherein the implant releases in vitro about 0.01        μg to about 0.15 μg of axitinib per day in phosphate-buffered        saline at 37° C. for a period of 30 days.    -   75. The sustained release biodegradable ocular implant of any of        items 68 to 74, wherein the implant releases in vitro about 35%        to about 45% of the axitinib in 3 days, about 65% to about 75%        of the axitinib in 7 days, and about 90% to about 100% of the        axitinib in 12 to 13 days in a 25:75 ethanol/water mixture (v/v)        at 37° C.    -   76. The sustained release biodegradable ocular implant of any of        items 68 to 75, wherein the implant releases in vitro about 25%        to about 35% of the axitinib in 2 months, about 47% to about 57%        of the axitinib in 3 months, about 70% to about 80% of the        axitinib in 5 months, and about 90% to about 100% of the        axitinib in 7 months in phosphate buffered saline at a pH of        7.2, at 37° C. and with an octanol top layer.    -   77. The sustained release biodegradable ocular implant of any of        items 68 to 76, wherein the implant is in the form of a fiber        that has an average length of about 15 mm to about 16.5 mm and        an average diameter of about 0.20 mm to about 0.30 mm in its        dried state.    -   78. The sustained release biodegradable ocular implant of item        77, which decreases in length and increases in diameter upon        hydration in vivo in the eye or in vitro, wherein hydration in        vitro is measured in phosphate-buffered saline at a pH of 7.2 at        37° C. after 24 hours.    -   79. The sustained release biodegradable ocular implant of item        77 or 78, wherein the implant in its hydrated state has an        average length of about 6.5 to about 8 mm and an average        diameter of about 0.70 to about 0.80 mm.    -   80. The sustained release biodegradable ocular implant of any of        items 68 to 79, wherein the implant is obtainable by preparing a        mixture containing hydrogel precursors and axitinib, filling the        mixture into a tubing, allowing the hydrogel to gel in the        tubing to provide a hydrogel shaped as a fiber, and stretching        the hydrogel fiber.    -   81. The sustained release biodegradable ocular implant of item        80, wherein the fiber is stretched after drying by a factor of        about 2 to about 5.    -   82. The sustained release biodegradable ocular implant of item        81, wherein the fiber is stretched after drying by a factor of        about 3 to about 4.5.    -   83. The sustained release biodegradable ocular implant of any of        items 68 to 82, wherein the implant in a dried state is loaded        in a needle, such as a 25-gauge needle or a 27-gauge needle, for        injection into the vitreous humor.    -   84. A sustained release biodegradable ocular implant containing        axitinib in an amount in the range from about 480 μg to about        750 μg dispersed in a hydrogel, wherein the hydrogel comprises a        polymer network.    -   85. The sustained release biodegradable ocular implant of item        84, wherein the polymer network comprises crosslinked        polyethylene glycol units.    -   86. The sustained release biodegradable ocular implant of item        85, wherein the axitinib is contained in an amount in the range        from about 540 μg to about 660 μg.    -   87. The sustained release biodegradable ocular implant of item        86, wherein the axitinib is contained in an amount of about 600        μg.    -   88. The sustained release biodegradable ocular implant of any of        items 84 to 87, wherein the polyethylene glycol units comprise        4-arm and/or 8-arm polyethylene glycol units having an average        molecular weight in the range from about 10,000 Daltons to about        60,000 Daltons.    -   89. The sustained release biodegradable ocular implant of item        88, wherein the polyethylene glycol units comprise 4a20kPEG        units.    -   90. The sustained release biodegradable ocular implant of item        89, wherein the polymer network is formed by reacting        4a20kPEG-SAZ with 8a20kPEG-NH₂.    -   91. The sustained release biodegradable ocular implant of item        90, wherein the weight ratio of 4a20kPEG-SAZ to 8a20kPEG-NH₂ is        about 2:1 or less.    -   92. The sustained release biodegradable ocular implant of any of        items 84 to 91, wherein the implant in a dried state contains        from about 45% to about 55% by weight axitinib and from about        37% to about 47% by weight polyethylene glycol units.    -   93. The sustained release biodegradable ocular implant of any of        items 84 to 92, wherein the implant in a dried state contains        not more than about 1% by weight water.    -   94. The sustained release biodegradable ocular implant of any of        items 84 to 93, wherein the implant is in the form of a fiber        that in its dried state has an average length of about 7 mm to        about 12 mm and an average diameter of about 0.25 mm to about        0.50 mm.    -   95. The sustained release biodegradable ocular implant of item        94, wherein the implant is in the form of a fiber that in its        dried state has an average length of about 8 mm to about 11 mm        and an average diameter of about 0.3 mm to about 0.4 mm.    -   96. The sustained release biodegradable ocular implant of any of        items 84 to 95, wherein the implant is for administration to the        vitreous humor.    -   97. The sustained release biodegradable ocular implant of item        94 to 96, which increases in diameter upon hydration in vivo in        the eye or in vitro, wherein hydration in vitro is measured in        phosphate-buffered saline at a pH of 7.2 at 37° C. after 24        hours.    -   98. The sustained release biodegradable ocular implant of item        97, wherein the implant in its hydrated state has an average        length of about 9 mm to about 12 mm and an average diameter of        about 0.5 mm to about 0.8 mm.    -   99. The sustained release biodegradable ocular implant of item        98, wherein the implant in its hydrated state has an average        length of about 9.5 mm to about 11.5 mm and an average diameter        of about 0.65 mm to about 0.75 mm, or has an average length in        its hydrated state of not more than about 10 mm or not more than        about 9 mm.    -   100. The sustained release biodegradable ocular implant of any        of items 84 to 99, wherein the implant contains about 600 μg        axitinib and releases in vitro about 0.3 μg to about 0.5 μg of        axitinib per day in phosphate-buffered saline at 37° C. for a        period of 30 days.    -   101. The sustained release biodegradable ocular implant of any        one of items 84 to 100, wherein the implant releases in vitro        about 40% to about 60% of the axitinib in 2 days, about 65% to        about 85% of the axitinib in 4 days, and about 75% to about 90%        of the axitinib in 6 days in a 25:75 ethanol/water mixture (v/v)        at 37° C.    -   102. The sustained release biodegradable ocular implant of item        101, wherein the implant releases in vitro about 45% to about        55% of the axitinib in 2 days, about 70% to about 80% of the        axitinib in 4 days, and about 80% to about 90% of the axitinib        in 6 days in a 25:75 ethanol/water mixture (v/v) at 37° C.    -   103. The sustained release biodegradable ocular implant of any        of items 84 to 102, wherein the implant is obtainable by        preparing a mixture containing hydrogel precursors and axitinib,        filling the mixture into a tubing, allowing the hydrogel to gel        in the tubing to provide a hydrogel shaped as a fiber, and        stretching the hydrogel fiber.    -   104. The sustained release biodegradable ocular implant of item        103, wherein the fiber is wet-stretched prior to drying by a        factor of about 0.5 to about 5.    -   105. The sustained release biodegradable ocular implant of item        104, wherein the fiber is wet-stretched prior to drying by a        factor of about 1 to about 4.    -   106. The sustained release biodegradable ocular implant of item        105, wherein the fiber is wet-stretched prior to drying by a        factor of about 1.5 to about 3.5.    -   107. The sustained release biodegradable ocular implant of item        106, wherein the fiber is wet-stretched prior to drying by a        factor of about 1.7 to about 3.    -   108. The sustained release biodegradable ocular implant of any        of items 84 to 107, wherein the implant in a dried state is        loaded in a needle for injection into the vitreous humor.    -   109. The sustained release biodegradable ocular implant of item        108, wherein the implant in a dried state is loaded in a        25-gauge or a 27-gauge needle.    -   110. The sustained release biodegradable ocular implant of any        of items 1 to 109, wherein the hydrogel comprises a polymer        network which is semi-crystalline in the dry state at or below        room temperature, and amorphous in the wet state.    -   111. The sustained release biodegradable ocular implant of any        of items 1 to 110, wherein the implant has undergone wet or dry        stretching during manufacture, and wherein the implant in the        stretched form is dimensionally stable when in the dry state at        or below room temperature.    -   112. A method of treating an ocular disease in a patient in need        thereof, the method comprising administering to the patient a        sustained release biodegradable ocular implant comprising a        hydrogel and a tyrosine kinase inhibitor according to any of the        preceding items, wherein the dose per eye administered once for        a treatment period of at least 3 months is from about 150 μg to        about 1200 μg of the tyrosine kinase inhibitor.    -   113. The method of item 112, wherein the tyrosine kinase        inhibitor is axitinib.    -   114. The method of item 112 or 113, wherein the dose        administered per eye once for the treatment period is in the        range from about 200 μg to about 800 μg.    -   115. The method of item 112 or 113, wherein the dose is in the        range from about 160 μg to about 250 μg, or from about 180 μg to        about 220 μg.    -   116. The method of item 115, wherein the dose is about 200 μg.    -   117. The method of item 112 or 113, wherein the dose is in the        range from about 320 μg to about 500 μg, or from about 360 μg to        about 440 μg.    -   118. The method of item 117, wherein the dose is about 400 μg.    -   119. The method of item 112 or 113, wherein the dose is in the        range from about 480 μg to about 750 μg, or from about 540 μg to        about 660 μg.    -   120. The method of item 119, wherein the dose is about 600 μg.    -   121. The method of item 112 or 113, wherein the dose is in the        range from about 640 μg to about 1000 μg, or from about 720 μg        to about 880 μg.    -   122. The method of item 121, wherein the dose is about 800 μg.    -   123. The method of any of items 112 to 122, wherein the ocular        disease involves angiogenesis.    -   124. The method of any of items 112 to 123, wherein the ocular        disease is mediated by one or more receptor tyrosine kinases        (RTKs), specifically VEGFR-1, VEGFR-2, VEGFR-3, PDGFR-α/β,        and/or c-Kit.    -   125. The method of any of items 112 to 124, wherein the ocular        disease is a retinal disease including Choroidal        Neovascularization, Diabetic Retinopathy, Diabetic Macular        Edema, Retinal Vein Occlusion, Acute Macular Neuroretinopathy,        Central Serous Chorioretinopathy, and Cystoid Macular Edema;        wherein the ocular disease is Acute Multifocal Placoid Pigment        Epitheliopathy, Behcet's Disease, Birdshot Retinochoroidopathy,        Infectious (Syphilis, Lyme, Tuberculosis, Toxoplasmosis),        Intermediate Uveitis (Pars Planitis), Multifocal Choroiditis,        Multiple Evanescent White Dot Syndrome (MEWDS), Ocular        Sarcoidosis, Posterior Scleritis, Serpignous Choroiditis,        Subretinal Fibrosis, Uveitis Syndrome, or Vogt-Koyanagi-Harada        Syndrome; wherein the ocular disease is a vascular disease or        exudative diseases, including Coat's Disease, Parafoveal        Telangiectasis, Papillophlebitis, Frosted Branch Angitis, Sickle        Cell Retinopathy and other Hemoglobinopathies, Angioid Streaks,        and Familial Exudative Vitreoretinopathy; or wherein the ocular        disease results from trauma or surgery, including Sympathetic        Ophthalmia, Uveitic Retinal Disease, Retinal Detachment, Trauma,        Photodynamic Laser Treatment, Photocoagulation, Hypoperfusion        During Surgery, Radiation Retinopathy, or Bone Marrow Transplant        Retinopathy.    -   126. The method of any of items 112 to 124, wherein the ocular        disease is neovascular age-related macular degeneration,        diabetic macular edema or retinal vein occlusion.    -   127. The method of item 126, wherein the disease is neovascular        age-related macular degeneration.    -   128. The method of any of items 112 to 127, wherein the        treatment is effective in reducing, essentially maintaining or        preventing a clinically significant increase of the central        subfield thickness as measured by optical coherence tomography        in a patient whose central subfield thickness is elevated.    -   129. The method of any of items 112 to 128, wherein the dose per        eye administered once for the treatment period is contained in        one implant or in two, three or more implants administered        concurrently.    -   130. The method of any of items 112 to 129, wherein the implant        is administered by injection into the vitreous humor.    -   131. The method of any of items 112 to 130, wherein the        treatment period is at least 3 about months, at least about 4.5        months, at least about 6 months, at least about 9 months, at        least about 11 months, at least about 12 months, at least about        13 months, or at least about 14 months.    -   132. The method of item 131, wherein the treatment period is at        least 6 months, at least about 9 months, or at least about 12        months.    -   133. The method of any of items 112 to 132, wherein concurrently        with the treatment with the sustained release ocular implant an        anti-VEGF agent is administered to the patient, or wherein an        anti-VEGF agent is administered within about 1, about 2 or about        3 months from the administration of the implant.    -   134. The method of item 133, wherein the anti-VEGF agent is        selected from the group consisting of aflibercept, bevacizumab,        pegaptanib, ranibizumab, and brolucizumab.    -   135. The method of item 134, wherein the anti-VEGF agent is        bevacizumab.    -   136. The method of any of items 133 to 135, wherein the        anti-VEGF agent is administered by means of intravitreal        injection.    -   137. The method of any of items 112 to 136, wherein the patient        receiving the implant has a history of an anti-VEGF treatment.    -   138. The method of any of items 112 to 136, wherein the patient        receiving the implant has no history of an anti-VEGF treatment        (anti-VEGF naïve).    -   139. A method of treating neovascular age-related macular        degeneration in a patient in need thereof, the method comprising        administering to the patient a sustained release biodegradable        ocular implant comprising a hydrogel that comprises a polymer        network and about 200 μg of a tyrosine kinase inhibitor, wherein        one implant per eye is administered once for a treatment period        of at least 9 months, and wherein the patient has a history of        an anti-VEGF treatment.    -   140. A method of treating neovascular age-related macular        degeneration in a patient in need thereof, the method comprising        administering to the patient a sustained release biodegradable        ocular implant comprising a hydrogel that comprises a polymer        network and about 200 μg of a tyrosine kinase inhibitor, wherein        two implants per eye forming a total dose of about 400 μg are        administered once for a treatment period of at least 3 months,        and wherein the patient has a history or has no history of an        anti-VEGF treatment.    -   141. The method of item 139 or 140, wherein the treatment        results in a reduction in central subfield thickness (CSFT) as        measured by optical coherence tomography during the treatment        period.    -   142. The method of any of items 139 to 141, wherein the tyrosine        kinase inhibitor is axitinib and is dispersed in the hydrogel        which comprises a polymer network formed by reacting        4a20kPEG-SAZ with 8a20kPEG-NH₂, and wherein the implant is in a        dried state prior to administration.    -   143. The method of item 142, wherein the hydrogel when formed        and before being dried contains about 7.5% polyethylene glycol,        representing the polyethylene glycol weight divided by the fluid        weight×100.    -   144. The method of any of items 140 to 143 wherein the treatment        period is at least 9 months.    -   145. A method of treating neovascular age-related macular        degeneration in a patient in need thereof, the method comprising        administering to the patient a sustained release biodegradable        ocular implant comprising axitinib in an amount in the range        from about 480 μg to about 750 μg dispersed in a hydrogel        comprising a polymer network, wherein the implant is        administered once for a treatment period of at least 3 months.    -   146. The method of item 145, wherein the axitinib is contained        in the implant in an amount from about 560 μg to about 660 μg,    -   147. The method of item 146, wherein the axitinib is contained        in the implant in an amount of about 600 μg.    -   148. The method of any of items 145 to 147, wherein the implant        is as defined in items 84 to 111.    -   149. The method of any of items 145 to 148, wherein the implant        is administered into the vitreous humor.    -   150. The method of any of items 145 to 149, wherein the        treatment period is at least about 3 months, at least about 6        months, at least about 9 months, at least about 11 months, at        least about 12 months, at least about 13 months, or at least        about 14 months.    -   151. The method any of items 145 to 150, wherein the implant is        administered by injection into the vitreous humor by means of a        25- or a 27-gauge needle.    -   152. The method of any of items 145 to 151, wherein the patient        receiving the implant has a history of an anti-VEGF treatment,        or has no history of an anti-VEGF treatment (anti-VEGF naïve).    -   153. The method of any of items 145 to 152, wherein an anti-VEGF        agent is administered to the patient concurrently with the        implant.    -   154. The method of item 153, wherein the anti-VEGF agent is        selected from the group consisting of aflibercept, bevacizumab,        pegaptanib, ranibizumab, and brolucizumab.    -   155. The method of item 154, wherein the anti-VEGF agent is        bevacizumab.    -   156. The method of any of items 153 to 155, wherein the        anti-VEGF agent is administered by means of intravitreal        injection.    -   157. The method of any of items 112 to 156, wherein the number        of adverse events during the administration of the sustained        release biodegradable ocular implant is low.    -   158. The method of item 157, wherein the number of        treatment-related ocular adverse events during the        administration of the sustained release biodegradable ocular        implant is low.    -   159. A method of manufacturing a sustained release biodegradable        ocular implant comprising a hydrogel and about 150 μg to about        1200 μg of a tyrosine kinase inhibitor according to any of items        1 to 111, the method comprising the steps of forming a hydrogel        comprising a polymer network and tyrosine kinase inhibitor        particles dispersed in the hydrogel, shaping the hydrogel and        drying the hydrogel.    -   160. The method of item 159, wherein the tyrosine kinase        inhibitor is axitinib.    -   161. The method of item 159 or 160, wherein the tyrosine kinase        inhibitor particles are micronized and/or homogeneously        dispersed within the hydrogel.    -   162. The method of any of items 159 to 161, wherein the polymer        network is formed by crosslinking multi-arm polyethylene glycol        units in a buffered solution.    -   163. The method of any of items 159 to 162, wherein the hydrogel        comprises a polymer network that is formed by mixing and        reacting an electrophilic group-containing multi-arm        polyethylene glycol with a nucleophilic group-containing        multi-arm polyethylene glycol in a buffered solution in the        presence of the tyrosine kinase inhibitor, and allowing the        mixture to gel.    -   164. The method of item 163, comprising reacting 4a20kPEG-SAZ        with 8a20kPEG-NH₂ in a weight ratio of about 2:1.    -   165. The method of item 163 or 164, wherein the method comprises        the steps of filling the mixture into a mold or tubing prior to        complete gelling in order to provide the desired final shape of        the hydrogel, allowing the mixture to gel, and drying the        hydrogel.    -   166. The method of item 165, wherein the mixture is filled into        a fine diameter tubing in order to prepare a hydrogel fiber.    -   167. The method of item 166, wherein the inside of the tubing        has a round geometry.    -   168. The method of item 166, wherein the inside of the tubing        has a non-round geometry.    -   169. The method of item 168, wherein the inside of the tubing        has a cross-shaped geometry.    -   170. The method of any of items 166 to 169, wherein the method        further comprises stretching the fiber and/or twisting the        fiber.    -   171. The method of item 170, wherein the stretching is performed        prior to or after drying the hydrogel.    -   172. The method of item 171, wherein the fiber is stretched by a        stretch factor of about 1 to about 4.5.    -   173. The method of item 171, wherein the implant contains        axitinib in an amount of about 200 μg and the stretching is        performed after drying the hydrogel by a stretch factor of about        2 to about 5 or a stretch factor of about 3 to about 4.5.    -   174. The method of item 171, wherein the implant contains        axitinib in an amount of about 600 μg and the stretching is        performed in a wet state prior to drying the hydrogel at a        stretch factor of about 0.5 to about 5, or a stretch factor of        about 1 to about 4, or a stretch factor of about 1.3 to about        3.5, or a stretch factor of about 1.7 to about 3.    -   175. The method of any of items 159 to 174, wherein the method        further comprises loading the implant in a dried state into a        needle.    -   176. The method of item 175, wherein the needle is a 25- or        27-gauge needle.    -   177. A method of imparting shape memory to a hydrogel fiber        comprising an active agent dispersed in the hydrogel by        stretching the hydrogel fiber in the longitudinal direction.    -   178. A method of manufacturing an ocular implant comprising a        hydrogel comprising an active agent dispersed therein, wherein        the implant changes its dimensions upon administration to the        eye, the method comprising preparing a fiber of the hydrogel and        stretching the fiber in the longitudinal direction.    -   179. The method of item 177 or 178, wherein the method comprises        the step of drying the hydrogel, wherein the fiber is stretched        in the longitudinal direction prior to or after said drying (wet        or dry stretching).    -   180. The method of any of items 177 to 179, wherein the fiber is        stretched by a factor of about 0.5 to about 5, or a factor of        about 1 to about 4.5, or a factor of about 3 to about 4.5 or a        factor of about 1 to about 2.    -   181. The method of any of items 177 to 180, wherein the active        agent is a tyrosine kinase inhibitor, such as axitinib.    -   182. The method of any of items 177 to 181, wherein the hydrogel        comprises a polymer network comprising crosslinked polyethylene        glycol units.    -   183. The method of any of items 177 to 182, wherein the fiber        upon hydration fully or partly returns to approximately its        original length and/or original diameter that it had prior to        the stretching.    -   184. The method of any of items 177 to 183, wherein the change        in dimensions is an increase in diameter, or an increase in        diameter together with a decrease in length.    -   185. A kit comprising one or more sustained release        biodegradable ocular implant(s) according to any of items 1 to        111 or manufactured in accordance with the method of any of        items 159 to 176 and one or more needle(s), wherein the one or        more needle(s) is/are each pre-loaded with one sustained release        biodegradable ocular implant in a dried state.    -   186. The kit of item 185, wherein the needle(s) is/are 25- or        27-gauge needle(s).    -   187. The kit of item 185 or 186, wherein the kit comprises one        or more 25- or 27-gauge needle(s) each loaded with an implant        containing axitinib in an amount in the range from about 180 μg        to about 220 μg.    -   188. The kit of item 187, wherein the implant contains axitinib        in an amount of about 200 μg.    -   189. The kit of item 185 or 186, wherein the kit comprises one        25-gauge or 27-gauge needle loaded with an implant containing        axitinib in an amount in the range from about 540 μg to about        660 μg.    -   190. The kit of item 189, wherein the implant contains axitinib        in an amount of about 600 μg.    -   191. The kit of any of items 185 to 190, further containing an        injection device for injecting the implant into the eye of a        patient.    -   192. The kit of item 191, wherein the injection device is        provided in the kit separately from the one or more needle(s)        loaded with implant.    -   193. The kit of item 191, wherein the injection device is        pre-connected to a needle loaded with implant.    -   194. The kit of item 191 or 192, wherein the injection device        contains a push wire to deploy the implant from the needle into        the eye.    -   195. The kit of any of items 185 to 194, further comprising one        dose of an anti-VEGF agent ready for injection.    -   196. An injection device suitable for injecting a sustained        release biodegradable ocular implant according to any of items 1        to 111 into the eye.    -   197. The injection device of item 196 containing means for        connecting the injection device to a needle,    -   198. The injection device of item 196 or 197, wherein the needle        is pre-loaded with the implant.    -   199. The injection device of any of items 196 to 198 containing        a push wire to deploy the implant from the needle into the eye        when the injection device has been connected to the needle.    -   200. The injection device of item 199, wherein the push wire is        made of Nitinol or stainless steel/Teflon.    -   201. The injection device of item 199 or 200, obtainable by        affixing the wire to the plunger and encasing it between two        snap fit injector body parts and securing the plunger with a        clip.    -   202. A pharmaceutical product comprising the sustained release        biodegradable ocular implant of any of items 1 to 111 loaded in        a needle and an injection device according to any of items 196        to 201, wherein the needle is pre-connected to the injection        device.    -   203. A sustained release biodegradable ocular implant containing        a tyrosine kinase inhibitor according to any of items 1 to 111        for use in treating an ocular disease in a patient in need        thereof according to any of items 112 to 138 or in treating        neovascular age-related macular degeneration in a patient in        need thereof according to any of items 139 to 158, 210 or 211.    -   204. Use of a sustained release biodegradable ocular implant        containing a tyrosine kinase inhibitor according to any of items        1 to 111 in the preparation of a medicament for the treatment of        an ocular disease in a patient in need thereof according to any        of items 112 to 138 or for the treatment of neovascular        age-related macular degeneration in a patient in need thereof        according to any of items 139 to 158, 210 or 211.    -   205. A method of reducing, essentially maintaining or preventing        a clinically significant increase of the central subfield        thickness as measured by optical coherence tomography in a        patient whose central subfield thickness is elevated due to an        ocular disease involving angiogenesis, the method comprising        administering to the patient the sustained release biodegradable        ocular implant containing a tyrosine kinase inhibitor according        to any of items 1 to 111.    -   206. The method of item 205, wherein the ocular disease is        neovascular age-related macular degeneration.    -   207. The method of item 205 or 206, wherein the central subfield        thickness is reduced, essentially maintained or a clinically        significant increase of the central subfield thickness is        prevented in the patient during a period of at least about 3        months, at least about 6 months, at least about 9 months, at        least about 11 months, at least about 12 months, at least about        13 months, or at least about 14 months after administration of        the implant with respect to a baseline central subfield        thickness measured in that patient prior to the administration        of the implant.    -   208. A sustained release biodegradable ocular implant containing        a tyrosine kinase inhibitor according to any of items 1 to 111        for use in reducing, essentially maintaining or preventing a        clinically significant increase of the central subfield        thickness as measured by optical coherence tomography in a        patient whose central subfield thickness is elevated due to an        ocular disease involving angiogenesis according to any of items        205 to 207, 210 or 211.    -   209. Use of a sustained release biodegradable ocular implant        containing a tyrosine kinase inhibitor according to any of items        1 to 111 in the preparation of a medicament for reducing,        essentially maintaining or preventing a clinically significant        increase in the central subfield thickness as measured by        optical coherence tomography in a patient whose central subfield        thickness is elevated due to an ocular disease involving        angiogenesis according to any of items 205 to 207, 210 or 211.    -   210. The method of any of items 128 to 158 or any of items 205        to 207, wherein the patient's vision expressed by means of the        best corrected visual acuity is not impaired, or is improved.    -   211. The method of any of items 128 to 158, any of items 205 to        207 or item 210, wherein rescue medication is not required to be        administered during the treatment period, or wherein rescue        medication is only required to be administered rarely, such as        1, 2 or 3 times, during the treatment period.    -   212. The method of item 211, wherein the duration of the        treatment period is from about 6 to about 9 months after        administration of the sustained release biodegradable ocular        implant.    -   213. A method of improving the vision of a patient whose vision        is impaired due to an ocular disease involving angiogenesis, the        method comprising administering to the patient the sustained        release biodegradable ocular implant containing a tyrosine        kinase inhibitor according to any of items 1 to 111.    -   214. The method of item 213, wherein the ocular disease is        neovascular age-related macular degeneration, diabetic macular        edema or retinal vein occlusion.    -   215. The method of item 213 or item 214, wherein the patient's        vision is impaired due to the presence of retinal fluid.    -   216. The method of any of items 213 to 215, wherein the        improvement of vision is manifested by means of an increase in        best corrected visual acuity.    -   217. The method of item 216, wherein the best corrected visual        acuity is increased by at least 10, at least 15, or at least 20        ETDRS letters.    -   218. A sustained release biodegradable ocular implant containing        a tyrosine kinase inhibitor according to any of items 1 to 111        for use in improving the vision of a patient whose vision is        impaired due to an ocular disease involving angiogenesis        according to the method of any of items 213 to 217.    -   219. Use of a sustained release biodegradable ocular implant        containing a tyrosine kinase inhibitor according to any of items        1 to 111 in the preparation of a medicament for improving the        vision of a patient whose vision is impaired due to an ocular        disease involving angiogenesis according to the method of any of        items 213 to 217.

Second List of Items

1. A sustained-release biodegradable ocular hydrogel implant comprisinga tyrosine kinase inhibitor, a polymer network, and a clearance zone,wherein the clearance zone is devoid of the TKI prior to release of theTKI.2. The ocular hydrogel of item 1, wherein the TKI is not in contact withretinal cells when the TKI is comprised inside the hydrogel implant.3. The ocular hydrogel of item 1 or 2, wherein the TKI is present in thehydrogel implant at or near its saturation level.4. The ocular hydrogel implant of any one of items 1 to 3, wherein thesize of the clearance zone increases as a function of the amount of TKIrelease.5. The ocular hydrogel implant of any one of items 1 to 4, wherein theocular hydrogel implant is fully degraded following release of the TKIor following release of at least 90% of the TKI.6. The ocular hydrogel implant of any one of items 1 to 5, wherein theocular hydrogel implant is fully degraded after about 30 days or afterabout 3 months following complete release of the TKI.7. The ocular hydrogel implant of any one of items 1 to 4, whereindegradation of the ocular hydrogel occurs prior to release of the TKI.8. The ocular hydrogel implant of any one of items 1 to 7, wherein thepolymer network comprises a plurality of polyethylene glycol (PEG)units.9. The ocular hydrogel implant of any one of items 1 to 8, wherein thepolymer network comprises a plurality of multi-arm PEG units.10. The ocular hydrogel implant of any one of items 1 to 9, wherein thepolymer network comprises a plurality of 4- or 8-arm PEG units.11. The ocular hydrogel implant of any one of items 1 to 9, wherein thepolymer network comprises a plurality of PEG units having the formula:

wherein n represents an ethylene oxide repeating unit and the wavy linesrepresent the points of repeating units of the polymer network.12. The ocular hydrogel implant of any one of items 1 to 11, wherein thepolymer network is formed by reacting a plurality of polyethylene glycol(PEG) units selected from 4a20k PEG-SAZ, 4a20k PEG-SAP, 4a20k PEG-SG,4a20k PEG-SS, 8a20k PEG-SAZ, 8a20k PEG-SAP, 8a20k PEG-SG, and 8a20kPEG-SS with one or more PEG or lysine based-amine groups selected from4a20k PEG-NH₂, 8a20k PEG-NH₂, and trilysine, or a salt thereof.13. The ocular hydrogel implant of any one of items 1 to 12, wherein thepolymer network is formed by reacting 4a20k PEG-SAZ with 8a20k PEG-NH₂.14. The ocular hydrogel implant of any one of items 1 to 13, wherein thepolymer network is amorphous (under aqueous conditions).15. The ocular hydrogel implant of any one of items 1 to 14, wherein thepolymer network is semi-crystalline in the absence of water.16. The ocular hydrogel implant of any one of items 1 to 15, wherein thetyrosine kinase inhibitor is homogenously dispersed within the polymernetwork.17. The ocular hydrogel implant of any one of items 1 to 16, wherein thetyrosine kinase inhibitor is released over a period of at least 15 days.18. The ocular hydrogel implant of any one of items 1 to 17, wherein thetyrosine kinase inhibitor is released over a period of at least 30 days.19. The ocular hydrogel implant of any one of items 1 to 18, wherein thetyrosine kinase inhibitor is released over a period of at least 60 days.20. The ocular hydrogel implant of any one of items 1 to 19, wherein thetyrosine kinase inhibitor is released over a period of at least 90 days.21. The ocular hydrogel implant of any one of items 1 to 20, wherein thetyrosine kinase inhibitor is released over a period of at least 180days.22. The ocular hydrogel implant of any one of items 1 to 21, wherein thetyrosine kinase inhibitor is released over a period of at least 365days.23. The ocular hydrogel implant of any one of items 1 to 22, wherein thetyrosine kinase inhibitor is in the form of an encapsulatedmicroparticle.24. The ocular hydrogel implant of any one of items 1 to 23, wherein thetyrosine kinase inhibitor is in the form of an encapsulatedmicroparticle comprising poly(lactic-co-glycolic acid).25. The ocular hydrogel implant of any one of items 1 to 24, wherein thetyrosine kinase inhibitor is selected from abemaciclib, acalabrutinib,afatinib, alectinib, axitinib, barictinib, binimetinib, brigatinib,cabozantinib, ceritinib, coblmetinib, crizotinib, dabrafenib,dacomitinib, dasatinib, encorafenib, erlotinib, everolimus,fostamatinib, gefitinib, gilteritinib, ibrutinib, imatinib,larotrectinib, lenvatinib, lorlatinib, axitinib, idelalisib, lenvatinib,midostaurin, neratinib, netarsudil, nilotinib, nintedanib, osimertinib,palbociclib, pazopanib, ponatinib, regorafenib, ribociclib, ruxolitinib,sirolimus, sorafenib, sunitinib, temsirolimus, tofacitinib, trametinib,vandetanib, and vemurafenib.26. The ocular hydrogel implant of item 1 or 25, wherein the tyrosinekinase inhibitor is axitinib.27. The ocular hydrogel implant of any one of items 1 to 26, wherein theocular hydrogel implant is injected into the vitreous humor, injectedinto the anterior chamber, or is affixed to the upper or lower punctumof the eye.28. A method of treating an ocular condition in a subject in needthereof, comprising injecting or affixing the ocular hydrogel implant ofany one of items 1 to 27 to the subject.29. The method of item 28, wherein the ocular condition is selected frommaculopathies, retinal degeneration, uveitis, retinitis, choroiditis,vascular diseases, exudative diseases, traumas, proliferative diseases,infectious disorders, genetic disorders, retinal tears, holes, andtumors.30. The method of item 28 or 29, wherein the ocular condition isselected from age-related macular degeneration, choroidalneovascularization, diabetic retinopathy, acute macularneuroretinopathy, central serous chorioretinopathy, cystoid macularedema, diabetic macular edema, acute multifocal placoid pigmentepitheliopathy, Behcet's disease, birdshot retinochoroidopathy,intermediate uveitis, multifocal choroiditis, multiple evanescent whitedot syndrome (MEWDS), ocular sarcoidosis, posterior scleritis,serpiginous choroiditis, subretinal fibrosis and uveitis syndrome,Vogt-Koyanagi-Harada syndrome, Coats disease, parafoveal telangiectasis,papillophlebitis, frosted branch angiitis, sickle cell retinopathy,angioid streaks, familial exudative vitreoretinopathy, sympatheticophthalmia, uveitic retinal disease, retinal detachment, proliferativediabetic retinopathy, ocular histoplasmosis, ocular toxocariasis, viralretinitis, acute retinal necrosis, ocular syphilis, ocular tuberculosis,congenital stationary night blindness, cone dystrophies, retinaldetachment, macular hole, giant retinal tear, solid tumors, posterioruveal melanoma, choroidal hemangioma, choroidal osteoma, choroidalmetastasis, retinoblastoma, vasoproliferative tumors of the ocularfundus, retinal astrocytoma, and intraocular lymphoid tumors.31. The method of item 29 or 30, wherein the condition is age-relatedmacular degeneration.32. The method of any one of items 29 to 31, wherein the subject waspreviously treated with an anti-VEGF therapy.

EXAMPLES

The following Examples are included to demonstrate certain aspects andembodiments of the invention as described in the claims. It should beappreciated by those of skill in the art, however, that the followingdescription is illustrative only and should not be taken in any way as arestriction of the invention.

Example 1: Preparation of Axitinib Implants

The axitinib implants of the present application are (essentially)cylindrical (and are also referred to herein as “fibers”), with axitinibhomogeneously dispersed and entrapped within a PEG-based hydrogel matrixto provide sustained release of axitinib based on its low aqueoussolubility in the vitreous humor of the eye.

The polymer network of the implants was formed by reacting 2 parts 4a20KPEG-SAZ (a 20 kDa PEG with 4 arms with a N-hydroxysuccinimidyl reactiveend group, sometimes also referred to as “NHS” end group) with 1 part8a20K PEG NH₂ (a 20 kDa PEG with 8 arms with an amine end group).Therefore, a polyurethane tubing was cut into appropriate length pieces.After that, an 8a20K PEG NH₂ sodium phosphate dibasic solution wasprepared and sterile filtered to remove endotoxins as well as otherparticles over 0.2 μm (pore size of the filter). The desired volume ofthe PEG amine solution was then weighed into a syringe. Next,corresponding amounts of solid axitinib depending on the desired finalaxitinib dose in the implant were weighed into another syringe. Thepowdered axitinib syringe and the PEG amine syringe were mixed carefullyto suspend and disperse the particles. The syringe comprising thesuspension mixture was then sonicated to break up any powderedagglomerates. After that, a 4a20K PEG SAZ sodium phosphate monobasicsolution was prepared and sterile filtered as described for the PEGamine solution. The desired volume of PEG SAZ solution was then weighedinto another syringe. In the next step, the ingredients of both syringes(4a20K PEG SAZ sodium phosphate monobasic solution and axitinib-8a20KPEG NH₂ mixture) were mixed to initiate the reaction leading togelation. The liquid suspension was cast through the preparedpolyurethane tubing before the material cross-links and solidifies.Gelling time was confirmed by performing a gel tap test. Thegel-comprising tubing was then placed into a high humidity curingchamber for 2 hours in order to prevent premature drying of the hydrogelprior to hydrogel gelation. In the chamber, the hydrogel axitinibsuspension in the tubing was allowed to cross-link to completioncreating a highly reacted and uniform gel, thus forming a hydrogelstrand.

After curing, different implant stretching methods were performed asdisclosed herein. Implants were either dry stretched or wet stretched asoutlined below. For dry stretching, strands were cut into shortersegments after curing and the strands were dried for 48 to 96 hours.After drying, dried strand segments were removed from the tubing andplaced on clamps of a custom stretcher. The strands were then slowly drystretched at a controlled rate to achieve the desired diameter that fitsinto a small gauge needle (stretch factor of about 2 to about 5, orabout 3 to about 4.5). The stretching step was performed in an oxygenand moisture free environment to protect the product. For wetstretching, strands were placed on clamps of a custom stretcher. Thestrands were then slowly wet stretched at a controlled rate to achievethe desired diameter that fits into a small gauge needle (stretch factorof about 1 to about 3, or about 1.3 to about 2.6). After stretching, thestrands were dried under tension under the conditions as described forthe dry stretching process.

The stretching creates a shape memory, meaning that the implant uponhydration when administered into the vitreous cavity of the eye willrapidly shrink in length and widen in diameter until it approaches itsoriginal wet casted dimension. While the narrow dry dimensionsfacilitate administration of the product through a smaller gauge needle,the widened diameter and shortened length after administration yield ashorter implant (in certain embodiments not much longer than about 10mm) in the posterior chamber relative to the eye diameter minimizingpotential contact with surrounding eye tissues. In general, the degreeof shrinking upon hydration depends inter alia on the stretch factor.For instance, stretching at e.g. a stretch factor of about 1.3 (wetstretching) will have a less pronounced effect or will not change thelength during hydration to a large extent. In contrast, stretching ate.g. a stretch factor of about 1.8 (wet stretching) will result in amarkedly shorter length during hydration. Stretching at e.g. a stretchfactor of about 4 (dry stretching) could result in a much shorter lengthupon hydration (such as, for example, a reduction in length from about15 to about 8 mm).

Stretched hydrogel strands were removed from the stretcher and then cutto the desired final length. The implant fibers were then placed on theinspection station. If the implants passed the quality control, theywere loaded into a 25 or 27 gauge needle (e.g. an FDA-approved 25G UTW½″ having an inner diameter of about 0.4 mm, or a 25G UTW 1″ or a 27G TW1.25″ needle) using a customized vacuum device and capped safely toavoid any needle tip damage.

The loaded needles were placed into a glove box for 6 to 9 days toremove any moisture (the remaining water content in the implant isintended to not exceed 1% water). All steps from then on were performedin the glove box. The loaded needle was dipped into a meltedlow-molecular weight 1k PEG to tip the needle. Upon cooling a hardenedsmall drop of PEG remains, which provides lubricity, keeps the implantin place within the needle, allows successful deployment and preventspremature rehydration of the implant within the needle duringadministration. Moreover, PEG tipping is minimizing tissue injury i.e.tissue coring, a process by which pieces of tissue are removed by aneedle as it passes through the tissue. The PEG-tipped needles were thenagain inspected, needles which did not meet the quality requirementswere discarded. Passed needles were again capped to ensure the needleswere not suffering any additional damage. Needles were then individuallypouched and sealed to prevent them from moisture and keep them sterile.The injection device, for instance a modified Hamilton glass syringe,had a push wire (e.g. a Nitinol push wire) that allows deploying theimplant from the needle more easily. The injection needle may contain astop feature that controls the injection depth. The injection device canbe separately packaged and sealed under nitrogen in foil pouches in thesame way as described for the needle (FIG. 1), or could be pre-assembledwith the implant-loaded needle or within a preloaded injector. Thepackaged needles and injection devices were removed from the glove boxand stored refrigerated (2-8° C.) prior to sterilization using gammairradiation. After sterilization the packages were stored refrigerated(2-8° C.) or frozen protected from light prior to use and wereequilibrated 30 min to room temperature prior to injection.

Administration of the implants occurs via intravitreal injection,wherein the implant localizes in the posterior segment of the eye (FIG.2). After injection, the implants hydrate in situ. Upon hydration uponcontact with the vitreous, the implant softens and increases in diameterand may also shrink in length. By trapping axitinib into the hydrogel adefined and limited localization of axitinib in the eye can be provided.The hydrogel matrix of the implant is formulated to biodegrade via esterhydrolysis in the aqueous environment of the vitreous. Axitinib releasesfor a sustained period from the hydrogel by diffusion into the vitreousand then into the surrounding ocular tissues based on the drug's lowsolubility under physiological conditions (FIG. 3). The drug releaserate from the implants is inter alia influenced by diffusion, drugclearance, vitreous viscosity, concentration gradients within andproximate to the implant, implant dose, implant surface area andgeometry, as well as the number of implants and their localizationwithin the vitreous.

Example 2: In Vitro Axitinib Release

In a next step, the release rate of axitinib from implants in differentformulations was determined by in vitro testing. The in vitro assays canbe additionally used for quality control of the implants.

In Vitro Axitinib Release Under Non-Sink Simulated PhysiologicalConditions

In one in vitro assay set-up, axitinib release was evaluated undernon-sink simulated physiological conditions at a daily replacementvolume comparable to the volume of vitreous humor in a human eye.

Three exemplarily selected implant formulations were examined (Table 1).Implant variants #1 and 2 were examined using one implant, implantvariant #3 using one and two implants (four conditions in total). Allconditions were conducted in duplicate.

TABLE 1 Formulation, configuration, and dry-dimensions of threeexemplarily selected axitinib implants. Formulation percentagesrepresent weight by weight (w/w). Implant variant Implant #1 Implant #2Implant #3 Formulation Axitinib 61.3% 61.3% 49.4% (amount per implant)(625 μg) (716 μg) (245 μg) 4a20k PEG-SAZ 21.1% 21.1% 27.7% 8a20k PEG-NH210.6% 10.6% 13.8% Sodium Phosphate  1.9%  1.9%  2.5% Monobasic SodiumPhosphate  5.0%  5.0%  6.6% Dibasic Configuration No. of Implants 1  1   1 or 2 Packaging Implant sealed in foil Implant sealed in foilImplant sealed in foil pouches and sealed pouches and sealed pouches andsealed under nitrogen. under nitrogen. under nitrogen. Glass vial w/5Glass vial w/5 Glass vial w/5 mL PBS. mL PBS. mL PBS. Storage FrozenFrozen Frozen Dimensions Dried Diameter (mm)  0.325  0.499  0.259 DriedLength (mm) 9.37 7.65 16.47

Prior to the performance of the in vitro release assay the starting drugcontent of the implants was examined by liquid chromatography coupled tofragmentation-based mass spectrometry (LC-MS/MS) using ethanol asextraction solvent (Table 2; for details on implant dissolution andLC-MS/MS reference is made to Example 3.5). The determined axitinibamounts matched well with the formulated amounts.

TABLE 2 Starting axitinib content in the implants as determined byLC-MS/MS. Condition Axitinib (μg) Implant #1 609 ± 48.1 Implant #2 720 ±35.4 Implant #3 × 2 458 ± 38.9 Implant #3 × 1 258 ± 33.9

In vitro released and non-released axitinib was determined for eachgroup without (control) and with daily release media sampling.

For control implant release, samples were placed in tubes. Five mL ofPBS (pH 7.2) were added to each tube on day 0 and the tubes were coveredwith a lid. Samples were then placed in a 37° C. incubator and gentlyrocked for 20 (1× implant #3) or 30 days (implant #1 and #2, 2× implant#3). At the end of the test period, the PBS was removed (1 mL PBS wassaved for testing). One mL of ethanol was added to the residual sample.Both PBS samples and residual samples were tested for axitinib amountreleased.

For daily implant release, samples were placed in tubes. Five mL of PBSwere added to each tube on day 0 and the tubes were covered with a lid.Samples were then placed in a 37° C. incubator and rocked gently. After24 hours, 4 mL of PBS were removed from each sample from which 1 mL wasused for testing and the remaining 3 mL were disposed. Four mL of freshPBS were added back into each tube. This process was repeated for 20 (1×implant #3) or 30 days (implant #1 and #2, 2× implant #3). On the finalday of the study, 1 mL of PBS was used for testing each sample and theremaining 4 mL were disposed. One mL of ethanol was added to theremaining residual implants and was tested for total remaining axitinib.

The axitinib concentration in PBS from control implant releasemeasurements after 20 or 30 days, respectively, represented a maximalsolubility determination of axitinib after prolonged incubation in therelease media (Table 3). The higher dose strengths resulted in higheraxitinib concentrations in the release media. The apparent maximalaxitinib solubility ranged from 0.24 to 0.40 μg/mL, which was consistentwith results reported in the literature for INLYTA® [NDA 202324].

TABLE 3 Control release data. Axitinib amounts and concentrations arepresented as mean and standard deviation (SD). Total Axitinib AxitinibAxitinib concentration Remaining Released in media Condition (μg) (μg)(μg/mL) Implant #1 595 ± 42.4 2.01 ± 0.004  0.40 ± 0.707 Implant #2 679± 48.8 1.90 ± 0.007 0.38 ± 1.41 Implant #3 × 2 458 ± 50.9 1.21 ± 0.0320.24 ± 6.36 Implant #3 × 1 251 ± 35.4 1.35 ± 0.449 0.27 ± 89.8

Test results demonstrated that the two high dose samples (implants #1and 2) released more axitinib per day than the lower dose groups (Table4). The amount of axitinib released per day over the study duration ispresented in FIG. 4A. The amount of total axitinib released was higherin the groups that removed and replaced PBS daily compared to the no PBSexchange (control). Implants #1 and #2 released more axitinib per daythan two implants of implant #3. The mean value of total axitinibreleased was slightly different in both high dose groups, but the medianamounts released daily were comparable, indicating no apparentdifference between the two higher dose groups.

TABLE 4 Daily sampling data. Axitinib amounts are presented as mean andstandard deviation (SD). Total Axitinib Axitinib Axitinib DailyRemaining Released Released Condition (μg) (μg) (μg) Implant #1 566 ±43.8 10.44 ± 0.35 0.36 ± 0.049 Implant #2 622 ± 43.8 11.48 ± 0.38 0.36 ±0.073 Implant #3 × 2 456 ± 16.3  5.26 ± 0.18 0.16 ± 0.044 Implant #3 × 1231 ± 6.36  2.26 ± 0.11 0.11 ± 0.019

The study results demonstrate that a single administration of an implantcontaining approximately 0.6 to 0.7 mg of axitinib releases moreaxitinib per day into solution in simulated physiological conditionsunder non-sink conditions at a volume representative of the vitreoushumor eye volume compared to the one or two lower dosage totalstrengths. Two implants containing approximately 0.2 mg each didn'trelease as much axitinib as a single higher dose implant under theseconditions. These in vitro results indicate that a single implant at ahigher dose may release more axitinib per day in the eye in the non-sinkconditions of the eye than two implants of a lower total dose.

In Vitro Axitinib Release Under Real-Time Sink Simulated PhysiologicalConditions

In another in vitro set-up, axitinib release was evaluated underreal-time sink simulated physiological conditions.

Therefore, implants were placed in 5 mL of a physiologically relevantmedia, i.e. PBS, pH 7.2 with 0.01% NaF with a layer of 1-octanol on topof the solution to provide a sink phase allowing transference of theaxitinib into the octanol layer. Implants were incubated under mildagitation at 37° C. in an air chamber. Axitinib was measured atpre-determined sampling time points in the octanol layer by taking theUV absorbance at 333 nm. The amount of axitinib released at each timepoint is determined relative to a standard curve prepared from anaxitinib reference. The accelerated in vitro release profile isdetermined as the percent of cumulative release of axitinib. Theduration to complete drug release was several months.

For an exemplarily release profile under real-time sink conditionsreference is made to FIG. 14A.

In Vitro Axitinib Release Under Accelerated Conditions

In a further in vitro set-up, axitinib release was evaluated underaccelerated conditions.

Therefore, the implants were placed into an ethanol and water mixture(25:75 ratio, v/v) to increase axitinib solubility at 37° C. in an airchamber with mild agitation. The solubility of axitinib in pure ethanolis 1.4 mg/mL and is approximately 19 μg/mL in a 25% ethanol/75% watermix (v/v; physiologically non relevant media). At pre-determinedsampling time points, an aliquot is removed and analyzed for axitinib bytaking the UV at 332 nm. The amount of axitinib released at each timepoint is determined relative to a standard curve prepared from anaxitinib reference. The accelerated in vitro release profile isdetermined as the percent of cumulative release of axitinib. Theduration of release under accelerated conditions is approximately twoweeks.

For an exemplarily release profile under accelerated conditionsreference is made to FIG. 14B (200 μg implant) and FIG. 4B (556 μgimplant).

Example 3: Evaluation of Axitinib Implants in Rabbits

In order to evaluate safety, tolerability, drug release, as well asefficacy of axitinib implants, several pre-clinical studies in Dutchbelted rabbits were performed. A broad range of doses were examinedeither delivered by one or more implants. An overview of the differentrabbit studies performed is presented in Table 5. Further studies wereperformed in beagle dogs and African green monkeys.

TABLE 5 Overview of pre-clinical studies with axitinib implants inrabbits. Drug dose and number of implants Example per eye (bilaterally)Study purpose No. Primary low-dose screen 15 μg axitinib in one implant;Safety, tolerability, 3.1 administration of one, two, or and efficacy atlow dose three implants Administration of one implant 227 μg axitinib inone implant; Tolerability, safety 3.2 administration of one implant andefficacy Administration of two implants 128 μg axitinib per implant,Tolerability and safety 3.3 total dose of 256 μg; administration of twoimplants Administration of two implants either with or withoutco-administration of Avastin ® 145 μg axitinib per implant,Tolerability, safety and 3.4 total dose of 290 μg; efficacy with andwithout administration of two implants co-administration of anti-VEGFdrug Drug release from axitinib implants 109 μg axitinib in one implant;Monitoring drug release 3.5 administration of one implant from theimplants in 227 μg axitinib in one implant; different eye tissues;administration of one implant Evaluation of systemic 145 μg axitinib perimplant, axitinib concentration total dose of 290 μg; administration oftwo implants 145 μg axitinib per implant, total dose of 290 μg withAvastin ®; administration of two implants Acute exposure to axitinib 600μg axitinib suspension Evaluation of safety of 3.6 injected intravitrealan axitinib bolus dose

Table 6 gives an exemplarily overview of formulations, configurations,and dimensions of implants used in animal studies (cf. Examples 3.2 to6). The dimensions of hydrated implants were examined after 24 hours inbiorelevant media (PBS, pH 7.2 at 37° C.). Although implant #5 showed aslight increase in length, the hydrated length was still below 10 mm.

TABLE 6 Formulation, configuration, and dimensions of different implants(#1 to #5) as used in animal studies. For instance, implant #4 was usedfor African green monkey studies (cf. Example 5). Formulationpercentages represent weight by weight (w/w). Implant type Implant #1Implant #2 Implant #3 Implant #4 Implant #5 Formulation Axitinib 54.6%54.7% 58.1% 54.8% 38.0% (amount per implant) (128 μg) (145 μg) (227 μg)(138 μg) (109 μg) PEG Hydrogel 37.2% total 37.1% total 29.1% total 37.0%total 50.9% total 4a20K PEG-SAZ 24.8% 24.7% 19.4% 24.7% 33.9% 8a20KPEG-NH2 12.4% 12.4%  9.7% 12.3% 17.0% Sodium phosphate  8.2%  8.2% 12.8% 8.1% 11.1% Configuration Stretching Method Dry Dry Dry Dry Wet NeedleSize 27G TW 1.25″ 27G TW 1.25″ 25G UTW 1″ 25G UTW 1″ 27G TW 1.25″Injector/Syringe 10 μL Modified 10 μL Modified 50 μL Modified 50 μLModified Implant Hamilton Hamilton Hamilton Hamilton Injector PackagingFoil Pouches Foil Pouches Foil Pouches Foil Pouches Foil Pouches PushWire Nitinol Wire Nitinol Wire Teflon Teflon Nitinol Wire StainlessSteel Stainless Steel Wire Wire Sterilization Type Gamma Gamma GammaGamma Gamma Site Storage Refrigerated Frozen Refrigerated RefrigeratedRefrigerated Dimensions Dried Diameter 0.20 mm 0.24 mm 0.24 mm 0.24 mm0.2 mm Length 12.4 mm 12.3 mm 12.5 mm 12.6 mm 7.0 mm Hydrated Diameter0.63 mm 0.64 mm 0.65 mm 0.67 mm 0.5 mm Length  5.1 mm  5.2 mm  5.5 mm 4.9 mm 9.2 mm

Prior to implant administration, animals were anesthetized with anintramuscular injection of ketamine hydrochloride (20 mg/kg) andxylazine (5 mg/kg). Eyes and the surrounding area were cleaned with a 5%Betadine solution and rinsed with balanced salt solution. One to twodrops of topical proparacaine hydrochloride anesthetic (0.5%) wasapplied. The eye was draped, and a sterile wire speculum was placed toretract the eyelids. The injection needle was placed approximately 3 to5 mm away from the limbus and deployed in a single stroke.

In summary, the axitinib implants showed a good safety profile, werewell tolerable and highly effective independent of the dose or way ofdelivery (by one or more implants). Moreover, the drug was efficientlyreleased in target tissues, while systemic concentrations in bloodremained very low or undetectable.

Example 3.1: Primary Low-Dose Screen of Axitinib Implants

For primary safety, tolerability, and efficacy investigation of theaxitinib-containing implants, a low dose of 15 μg axitinib per implantwas administered as either one (group 1, n=5), two (group 2, n=5) orthree implants (group 3, n=5) per eye bilaterally via intravitrealinjection using a 30G 0.5″ needle in rabbits including control animalsreceiving saline. The implants used in this study had a diameter of0.15±0.13 mm and a length of 6.9±0.1 mm in a dried state. Afterhydration for 24 hours in biorelevant media (PBS, pH 7.2 at 37° C.) thediameter was 0.42±0.02 mm and the length was 10.6±0.4 mm.

Over a time of 1 month, general health, body weights, and intraocularpressure (IOP) were recorded. Clinical ophthalmic exams were scored atbaseline and at 1 month according to the modified McDonald-Shadduckscoring system (McDonald, T. O., and Shadduck, J. A. “Eye irritation”.Advances in Mondern Toxicology, IV: Dermatotoxicology and Pharmacology,1977). Infrared reflectance (IR) imaging was collected at 1 month forrepresentative images of the one, two and three implants in thevitreous. Ocular distribution of axitinib was examined using LC-MS/MSessentially as described under Example 3.5. In order to evaluateefficacy of the implants, the rabbits with and without implants werechallenged by recurring intravitreal injection of VEGF to induce retinalvascular leakage essentially as described under Example 3.2.

No notable effects on body weight were observed in none of the groups.Moreover, IOP values were normal and comparable between all groups.Ocular health was not or only mildly affected indicating overall safetyand tolerability. Clinical ophthalmic examinations at one-monthdemonstrated no ocular findings for any animals administered a singleimplant. Mild corneal opacity was observed in one eye of animalsadministered two or three implants. Mild and moderate conjunctivaldischarge was observed in two eyes of animals administered threeimplants.

IR imaging revealed that the overall shape of the implants,independently of the number administered, remained intact (FIG. 5A).

Pharmacokinetic results of axitinib concentrations in the ocular tissuesat 1 month for each group are presented in Table 7. Two eyes wereexcluded from analysis because one eye in the retina tissue samples ingroup 2 and one eye in the choroid/RPE (retinal pigment epithelium)samples in group 3 likely included a portion of the implant creatingerroneously high concentrations in those two tissue samples due topreferential dissolution in the extraction organic solvent systememployed prior to LC-MS/MS analysis (cf. Example 3.5). The solubility ofaxitinib in PBS, pH 7.2 at 37° C. was determined to be approximately 0.5μg/mL and any tissue values markedly higher than this potentiallyindicates either tissue accumulation or sample contamination. Axitinibconcentrations were either low or absence in the AH compared to theother ocular tissues indicating little migration of axitinib from theposterior chamber to the anterior chamber. The ocular distributionresults demonstrated that a single implant dose (group 1) appeared to bealmost fully depleted at 1 month with only 0.3 μg remaining in the VH.25.5 μg were released from the 30 μg starting dose (two implants, group2) over the first month for a daily release rate of approximately 0.8μg/day. 33.8 μg were released from the 45 μg starting dose (threeimplants, group 3) over the first month for a daily release rate ofapproximately 1.1 μg/day. Median axitinib levels in the retina were 31ng/g for group 1, 65 ng/g for group 2 and 148 ng/g for group 3demonstrating a dose dependent release into the retina tissue.Saturation was not achieved in this study.

TABLE 7 Ocular tissue distribution of axitinib released from 1, 2, and 3implants with an axitinib dose of 15 μg per implant (groups 1, 2, and 3,respectively). Axitinib concentrations in AH, retina, and choroid/RPE,as well as remaining axitinib in the implant (recovered from the VH) arepresented after 1 month as average (mean) including standard deviation,coefficient of variation (CV) as well as the confidence interval (CI) ofthe mean. In addition, minimum, median, and maximum values for each datapoint are presented. N 95% Tissue Group Eyes Average Min. Median Max. SDCV CI AH 1 10 0.1 0.0 0.0 0.3 0.1 213%  0.1 (ng/mL) 2 9 0.1 0.0 0.0 0.30.1 203%  0.1 3 9 0.1 0.0 0.0 0.2 0.1 198%  0.1 Retina 1 10 43 18 31 10830 69% 18 (ng/g) 2 9 86 39 65 230 59 69% 39 3 9 200 64 148 455 123 61%80 Choroid/RPE 1 10 95 0 32 464 151 159%  94 (ng/g) 2 9 154 0 104 332115 75% 75 3 9 175 49 110 526 156 89% 102 VH + Implant 1 10 0.4 0.0 0.31.1 0.4 97% 0.2 (μg) 2 9 4.4 1.2 4.5 7.3 2.2 50% 1.5 3 9 11.2 6.3 11.216.9 3.4 30% 2.2

Of note, all three doses demonstrated inhibition of vascular leakageafter the VEGF challenge at one month compared to control animals (n=3)not having an implant indicating that even the lowest dose (15 μg)exhibited good efficacy even after short times of 1 month (FIG. 5B).

In summary, the TKI implants administered either as one, two, or threeimplants per eye were successfully validated for safety, tolerability,as well as axitinib release and efficacy in the primary low dose study.

Example 3.2: Tolerability, Safety and Efficacy Studies with One AxitinibImplant

In order to study the tolerability, safety and efficacy of one implantper eye with a higher axitinib dose, rabbits were administeredbilaterally via intravitreal injection with a 25G ultra-thin wall needleone implant per eye with an axitinib dose of 227 μg. For implantdimension reference is made to Table 6 (implant type #3).

Tolerability and Safety

For tolerability and safety studies, 9 animals were monitored over 6months for general health (daily), body weight (0, 1, 3, 6 months) andIOP and ophthalmic exams (each in 0.5 months intervals). Clinicalophthalmic exams were scored according to the modified McDonald-Shadduckscoring system. Electroretinography (ERG) and fluorescein angiography(FA) were performed at 1, 3, and 6 months to assess retinal function andto evaluate the vasculature of the eye, respectively. Optical coherencetomography (OCT) was performed monthly to obtain cross-sectional imagesof the retina. IR imaging was performed monthly to monitorbiodegradation of implants over the time and persistence of axitinib inthe vitreous.

Upon sacrifice (3 animals at 1, 3, and 6 months), whole eyes wereprepared for histopathological analysis. Therefore, a suture was placedat the 12 o'clock position for orientation and harvest. Typically, eyeswere trimmed in half in the plane from 12 o'clock to 6 o'clock throughthe lens and optic nerve along the midline. This captures as many opticstructures in one plane as possible. The trimmed eyes were examinedgrossly and abnormalities noted. Hematoxylin and eosin (H&E)-stainedslides were prepared that were separated by 1 mm. Each slide contained 2serial sections. Histopathology assessments at each time point includedvitreous, retinal, scleral, or episcleral inflammation, retinaldisruption and fibrosis around the injected area. Scoring was performedon a semi-quantitative scale from 0-5 for any abnormalities, where 0denotes no change (normal), 1 denotes rare foci of change (minimal), 2denotes mild diffuse change or more pronounced focal change, 3 denotesmoderate diffuse change, 4 denotes marked diffuse change and 5 denotessevere diffuse change.

No notable effects on daily health or body weights were observed. IOPwas normal for the complete duration of the study. No notable effectsfrom the implants were found based on electroretinography (ERG)measurements. Fluorescein angiography (FA) and OCT imaging revealed nopathologies over the study. For instance, normal retinal morphology waspreserved over 6 months (FIG. 6). In addition, ophthalmic exam findingswere normal or mild. IR imaging at weeks 4 and 8 revealed an intactimplant, whereas images at week 12 demonstrated early stages of hydrogeldegradation (FIG. 7A). Images at week 16 showed implant narrowing due toloss of hydrogel structure. Finally, images at weeks 20 and 26 showedthe absence of hydrogel, while non-dissolved axitinib particles remainedin proximity to the former implant site and formed a single monolithicstructure. However, any undissolved axitinib remaining at the implantsite was shown to continue to release axitinib at levels sufficient forinhibition of vascular leakage (as demonstrated for instance through 21months in a VEGF-challenge study, see Example 3.4). In addition, noinflammation was observed in the region of undissolved axitinibparticles (FIG. 7B).

The amount of axitinib decreased in the histopathology sections overtime indicating bio-resorption of the injected material. There were noobservations of gross lesions in the sections noted over the studyduration. Mean histopathology results with standard deviations arepresented in Table 8. Mean inflammation scores showed that retinal,scleral, or episcleral, vitreous chamber and chronic subcorneal(lymphocytes and phagocytes at cornea edges) inflammation scores werenormal to minimal over the study duration. Mean fibrosis scores aroundthe injected test article were normal to minimal over the studyduration. Mean retinal disruption scores were minimal over the studyduration. Mean retinal vacuolization scores were minimal over the studyduration. Retinal detachments were not observed clinically, but werenoted in 1 of 68, 5 of 71, and 1 of 72 histologic sections for months 1,3 and 6, respectively. The position of the detachments was oftenassociated with retinal disruption sites and are consistent with theneedle penetration site position, indicating that they were likelyprocedure related.

TABLE 8 Histopathological analysis results for rabbits with one implant(227 μg axitinib per implant). Results were scored on a scale of 0-5,where 0 denotes no change (normal), 1 denotes rare foci of change(minimal), 2 denotes mild diffuse change or more pronounced focalchange, 3 denotes moderate diffuse change, 4 denotes marked diffusechange and 5 denotes severe diffuse change. Results are presented asmean and standard deviation (SD). Vitreous Retinal, Scleral, FibrosisChronic Retinal Retinal Chamber or Episcleral Around the SubcornealMonth Disruption Vacuolization Inflammation Inflammation ImplantInflammation 1 0.03 (0.06) 0.40 (0.24) 0.07 (0.16) 0.02 (0.04) 0.02(0.04) 0.02 (0.04) 3 0.05 (0.06) 0.57 (0.21) 0.07 (0.05) 0.18 (0.05)0.00 (0.00) 0.10 (0.20) 6 0.03 (0.05) 0.82 (0.25) 0.30 (0.28) 0.05(0.08) 0.03 (0.05) 0.40 (0.20)

Efficacy

For efficacy studies, 12 animals (with and without the implant) receivedan intravenously VEGF challenge (1 μg) 48 hours prior to selected timepoints (1, 2, 3, and 6 months after implant injection; 3 animalseuthanized at each time point) to induce vascular proliferation andleakage. Rabbits were followed for 6 months from the administration ofthe implant. Eyes were imaged 48 hours post VEGF challenge usingfluorescein angiography (FA) after intravenous injection of fluoresceinand were graded on a scale from 0 to 4 (Table 9). Each eye was scored onthe left and right side to account for non-uniformity in inflammatoryresponse. FA scores were then averaged for each eye.

TABLE 9 Description of scoring method for imaging by fluoresceinangiography (FA). Score Description 0 Normal eye, vessels appearstraight and simple, no haziness or leakage 1 Some minor tortuosity, butgenerally vessels appear straight, no haziness or leakage 2 Some moreadvanced tortuosity, vessels appear choked and a lot of branching isvisible, but still no haziness or leakage 3 Extreme tortuosity, vesselsappear choked and a lot of branching is visible, some slight hazinesspointing to leakage of the vessels 4 Extreme tortuosity and extremeleakage, eye appears as a haze and vessels are difficult to visualize

Vascular leakage was effectively reduced in animals with the implantwhen compared to control animals that received saline instead of theimplant over a period of 6 months (FIG. 8). Blank control eyes showedhigh tortuosity and leakage at all time-points.

Taken together, the data demonstrate good tolerability and safety of onehigher dose implant, as well as suitable biodegradation rates and thepotential of the implant to inhibit neovascularization in vivo.

Example 3.3: Tolerability and Safety Studies with Two Axitinib Implants

In a next step, tolerability and safety of two implants with higheraxitinib dose (128 μg per implant, total dose of 256 μg per eye) wereinvestigated. Therefore, rabbits (n=9) received two implants (implanttype #1 in Table 6) bilaterally with a total axitinib dose of 256 μg(128 μg per implant) via intravitreal injection with a 27G ultra-thinwall needle.

Over a study period of 6.5 months, rabbits were daily monitored forhealth, IOP, and body weight. Clinical ophthalmic exams (daily) werescored according to the modified McDonalds-Shadduck scoring system.Optical coherence tomography (OCT) was performed to obtaincross-sectional images of the retina (monthly). Infrared (IR) imagingwas performed to monitor the persistence and degradation of implants andaxitinib in the vitreous (monthly). Electroretinography (ERG) wasperformed to assess retinal function and fluorescein angiography (FA)was performed to evaluate the vasculature of the eye at months 1, 3, and6.5. At months 1, 3, and 6.5, each 3 rabbits were sacrificed. Aftersacrifice, whole eyes were prepared for histopathological analysis (cf.Example 3.2).

No abnormal general health observations were observed. All rabbitseither gained or maintained weight over the study duration. Ocularhealth findings were limited to irritation, swelling, and/or dischargethat were sporadic, generally mild and transient. Clinical ophthalmicexaminations demonstrated no ocular abnormalities over the course of thestudy, except of mild conjunctival discharge for half of the animals atday 14, likely procedure related, which resolved by day 27, a singleinstance of mild retina hemorrhage immediately post-administration whichresolved by day 27, mild conjunctival congestion seven weeks postadministration, and lens opacity due to attachment of the implant to thelens in one eye at day 195. IOP was normal for the duration of thestudy. OCT imaging revealed no retinal abnormalities over the studyduration. ERG was normal for all study eyes, indicating normal retinalfunction. FA found normal vascularization and no evidence of dilation orleakage.

IR imaging demonstrated hydrogel degradation of the two implants overtime and a more monolithic morphology was formed as the axitinibparticles were released from the confines of the hydrogel, as seen postday 117 (FIG. 9). These observations were similar to the implantbehavior in Example 3.2 (FIG. 7A).

Histopathology noted that the amount of the test article declined in thesections over time, indicating bioresorption of the injected material.Histopathological findings assessing inflammation and fibrosis wereabsent or minimal over the study duration. Mean histopathology resultswith standard deviations are presented in Table 10. Meanhistopathological inflammation scores showed that retinal, scleral, orepiscleral, vitreous chamber and chronic subcorneal (lymphocytes andphagocytes at cornea edges) inflammation scores were normal to minimalover the study duration. Mean fibrosis scores around the injected testarticle were normal to minimal over the study duration. Mean retinaldisruption scores were normal to minimal over the study duration. Meanretinal vacuolization scores were minimal over the study duration.Retinal detachments were not observed clinically, but were noted in 2 of192 histologic sections for months 1, 3, and 6, respectively. Theposition of the detachments was often associated with retinal disruptionsites and are consistent with the needle penetration through the retinaat the injection location indicating that they were likely procedurerelated.

TABLE 10 Histopathological analysis results for rabbits with twoimplants (total dose of 256 μg axitinib per eye). Results were scored ona scale of 0-5, where 0 denotes no change (normal), 1 denotes rare fociof change (minimal), 2 denotes mild diffuse change or more pronouncedfocal change, 3 denotes moderate diffuse change, 4 denotes markeddiffuse change and 5 denotes severe diffuse change. Results arepresented as mean and standard deviation (SD). Vitreous Retinal,Scleral, Fibrosis Chronic Retinal Retinal Chamber or Episcleral Aroundthe Subcorneal Month Disruption Vacuolization Inflammation InflammationImplant Inflammation 1 0.03 (0.06) 0.50 (0.31) 0.15 (0.23) 0.02 (0.04)0.00 (0.00) 0.58 (0.31) 3 0.00 (0.00) 0.36 (0.39) 0.06 (0.09) 0.00(0.00) 0.00 (0.00) 0.58 (0.48) 6.5 0.02 (0.04) 0.28 (0.41) 0.02 (0.04)0.04 (0.05) 0.02 (0.04) 0.42 (0.38)

Example 3.4: Tolerability, Safety and Efficacy Studies with Two AxitinibImplants with or without Co-Administration of Avastin®

In a next step, the tolerability, safety and efficacy of two axitinibimplants (145 μg axitinib resulting in a dose of 290 μg per eye)bilaterally administered via intravitreal injection with a 27Gultra-thin wall needle was assessed with and without co-administrationof 1.25 mg Avastin® (bevacizumab). For the animals receiving Avastin®,the anti-VEGF therapeutic was administered intravitreally followed byadministration of the two implants. For formulation and dimensions ofthe implants applied in this study, reference is made to Table 6(implant type #2).

Tolerability and Safety

For tolerability and safety studies, 30 rabbits (n=15 per group, whereingroup 1 did not receive Avastin® and group 2 received 1.25 mg Avastin®)were monitored for a study time of up to 38 months. General health waschecked on a daily basis until 31 months and body weight was checked ona daily basis until 21 months. In addition, IR imaging was performed tomonitor persistence and degradation of the implants and axitinib in thevitreous over 38 months. Ophthalmic exams and IOP were monitored for 21months. Ophthalmic exams were scored according to the modifiedMcDonald-Shadduck scoring system.

In summary, no effects on body weight were observed. Daily generalhealth observations solely revealed limited to mild ocular findingswhich self-resolved. IOP and ocular exams were normal throughout thestudy. Ophthalmic findings were generally mild in nature for vitreousflare, choroidal/retinal inflammation, and conjunctival discharge. Allfindings were comparable between implants applied with or withoutco-administration of Avastin® demonstrating the suitability of theimplants to be combined with other therapeutics such as anti-VEGFmedicals.

IR imaging confirmed that the implants dissociated over the studyduration and demonstrate hydrogel degradation of the two implants overtime and a more monolithic morphology was observed as the axitinibparticles merge into a single monolithic structure between 6 and 9months, wherein the structure demonstrated a reduction in size throughstudy completion (FIG. 10). These observations were also in line withimages from Examples 3.2 and 3.3 (FIGS. 7A and 9).

Efficacy

For efficacy studies, 52 rabbits were divided in 4 groups, wherein group1 received the two implants but did not receive Avastin® (n=15), group 2received the two implants and received Avastin® (n=15), group 3 solelyreceived Avastin® (n=9), and group 4 were control rabbits withoutimplant receiving saline (n=13). Animals from each group wereintravenously challenged with VEGF (1 μg) 48 hours prior to selectedtime points (0.5, 1, 3, 6, 9, 12, 14, 16, 19, 20, and 21 months) toinduce vascular proliferation and leakage. Eyes were imaged 48 hourspost VEGF challenge time-points using fluorescein angiography (FA) andwere graded on a scale from 0 (normal) to 4 (severe leakage) asdescribed under Example 3.2.

It was demonstrated that vascular leakage was prevented with and withoutthe co-administration of Avastin® for up to 21 months with repeated VEGFchallenges (FIG. 11). Representative FA images at 1 month post implantinjection clearly show effective leakage inhibition 1 month afterimplant injection for animals of group 2 (FIG. 12). Of note, animalssolely receiving Avastin® (group 3) showed rapid leakage inhibitionwithin the first 2 and 4 weeks, however, after 3 months vascular leakagere-occurred to a similar degree than observed in the control animals(group 4; FIG. 13). Blank control eyes showed high tortuosity andleakage at all time-points (Score 3-4).

Taken together, the VEGF challenging data demonstrated the potential ofthe implants to inhibit neovascularization in vivo in line with the goodefficacy resulting from one implant (cf. Example 3.2). Compared toanimals solely receiving Avastin®, the beneficial effect of the implantswas demonstrated. In contrast to the anti-VEGF therapeutic where effectsonly lasted until 3 months post injection, the implants enabled along-term inhibition of neovascularization of up to 21 months.

Example 3.5: Axitinib Release from Implants and Axitinib Distribution inRabbits

Finally, pharmacokinetic studies have been performed in order toevaluate drug-release from the implants and axitinib distribution to theocular tissues, specifically the retina, choroid/retinal pigmentepithelium (RPE), vitreous humor (VH) and aqueous humor (AH) over timefollowing sustained release from the implants. In addition, systemicaxitinib concentrations were monitored. Therefore, rabbits were dividedinto 4 groups. 2 groups received bilaterally one implant comprisingeither 109 μg axitinib (group 1, n=14) or 227 μg axitinib (cf. Example3.2, group 2, n=24). Group 3 (cf. Example 3.4; n=15) receivedbilaterally two implants, each comprising 145 μg, i.e., a total dose of290 μg axitinib. Group 4 (cf. Example 3.4; n=15) received bilaterallytwo implants comprising, as for group 3, a total dose of 290 μg axitinib(2×145 μg) and in addition 1.25 mg Avastin® (bevacizumab) intravitreal.Formulations, configurations, and dimensions of implants withcorresponding axitinib doses are presented in Table 6.

For investigation of drug release, two rabbits were euthanized pertime-point for group 1 (day 1 and 1.5, 3, 4.5, 6, 7.5 and 9 months), sixrabbits were euthanized per time-point for group 2 (1, 3, 6, and 7months), and 3 (0.5, 1, 3, and 6 months) and 1 (9 and 38 months) rabbitswere euthanized per time-point for groups 3 and 4. In addition, bloodsamples were taken from the rabbits prior to euthanasia at time pointsindicated in Table 11.

Methods Determination of Axitinib in Plasma

For determination of axitinib in plasma, two equivalent quantificationmethods were carried out. Axitinib was extracted from plasma bysupported liquid extraction (SLE) and was dried under nitrogen. Theshort-term matrix (plasma) stability was up to 4 hours and the extractstability was up to 116 hours.

After reconstitution in methanol/water (50:50 v/v; method 1) oralternatively in methanol/water/formic acid (75:25:0.01 v/v/v; method2), the samples were analyzed by liquid chromatography-tandem massspectrometry (LC-MS/MS; API 4000, Applied Biosystems) using awater/formic acid/methanol gradient. Axitinib and the internal standard(IS; axitinib-D3 for method 1 and pazopanib for method 2) were separatedon an YMC-Pack Pro C4 column (50×3.0 mm I.D.; method 1) or a PhenomenexLuna C18 column (method 2) and quantitated using electrospray ionization(ESI) selective reaction monitoring mode with a total run time ofapproximately 6 min. For quantification, the peak area of axitinib (m/z387.2 to 356.0) and the IS (m/z 390.2 to 356.0 for axitinib-D3 and m/z438.2 to 357.1 for pazopanib) were determined and compared to a standardcurve, which showed linear behavior in the desired concentration rangeand a correlation coefficient (r²) of >0.99. The lower limit ofquantitation (LLOQ) ranged from about 0.01 ng/mL to about 0.36 ng/mLdepending on the study group and sampling time-points (Table 11).

TABLE 11 Sampling time points and corresponding LLOQ (by isomer) foraxitinib in plasma or serum. For group 1, plasma samples were analyzedon day 1 and 1.5, 3, 4.5, 6, 7.5 and 9 months. For group 2, plasmasamples were analyzed after 3, 6, and 7 months. For groups 3 and 4,serum samples were analyzed after 6 months. Study Group Sampling timepoints (LLOQ depending on isomer) Group 1 Day 1 and 1.5, 3, 4.5, 6, 7.5and 9 months (0.0500 ng/mL; both isomers) Group 2 3 months (0.355 ng/mL(trans), 0.146 ng/mL (cis)) 6 months (0.0717 ng/mL (trans), 0.0283 ng/mL(cis) 7 months (0.0158 ng/mL (trans), 0.0106 ng/mL (cis)) Groups 3 and 46 months (0.0452 ng/mL (trans), 0.00970 ng/mL (cis))

Methods Determination of Axitinib in Ocular Tissues

For determination of axitinib concentrations in ocular tissues, eyeswere enucleated and frozen in liquid nitrogen at the selected timepoints (Table 13). The eyes were stored frozen prior to frozendissection and subsequent bioanalysis. For determination of axitinib inocular tissues, two equivalent quantification methods were carried out.Equivalency of both methods to determine the axitinib concentrations inAH, VH, retina and choroid homogenate was demonstrated duringqualification.

Ocular tissue samples of retina and choroid were homogenized in amethanol/water diluent (50:50, v/v; method 1) or in phosphate bufferedsaline (PBS; method 2) in tubes containing ceramic beads. Solubleaxitinib in VH and AH was diluted directly from the samples withmethanol/water diluent (50:50, v/v) and vitreous humor samplescontaining the implant (undissolved axitinib) were extracted withethanol (method 1). In method 2, homogenized tissues, soluble axitinibin VH and AH were diluted with methanol/water/formic acid (75:25:0.01v/v/v). Analyte was extracted from the matrix by protein precipitation(method 1) or SLE (method 2), respectively. The short-term matrixstability was up to 5 hours (AH), up to 5.5 hours (VH), up to 6.6 hours(retina) and up to 4.5 hours (choroid). The extract was stable up to 171hours (AH), up to 153 hours (VH), up to 115 hours (retina) and up to 114hours (choroid).

Samples were dried under nitrogen and reconstituted with methanol/water(50:50 v/v) and are analyzed via LC-MS/MS (API 4000, Applied Biosystems)with a water/formic acid/acetonitrile gradient (method 1) or awater/formic acid/methanol gradient (method 2). Axitinib and theinternal standard (IS; axitinib-D3 for method 1 and pazopanib for method2) were separated on an YMC-Pack Pro C4 column (50×3.0 mm I.D.;method 1) or a Phenomenex Luna C18 column (method 2) and quantitatedusing ESI selective reaction monitoring mode with a total run time ofapproximately 6 min. For quantification, the peak area of axitinib (m/z387.2 to 356.0) and the IS (m/z 390.2 to 356.0 for axitinib-D3 and m/z438.2 to 357.1 for pazopanib) were determined and compared to a standardcurve, which showed linear behavior in the desired concentration rangeand a correlation coefficient (r²) of >0.99. The LLOQ was 0.100 ng/mL.

Results: Determination of Axitinib in Plasma

The axitinib concentration in plasma and serum was determined atindicated time-points in the different groups (Table 11). Determinedconcentrations were below the lower limit of quantitation (LLOQ) duringthe duration of the studies for all groups independent of the axitinibdose (ranging from 109 to 290 μg per eye), demonstrating that thesystemic exposure to axitinib was near absent even for a total dose ashigh as 580 μg axitinib (290 μg axitinib per eye adding up to a total of580 μg per rabbit). This further underlines safety of the implants evenfor higher doses.

After hydrogel degradation, undissolved axitinib was observed to form alocalized structure continuing to release axitinib (cf. Examples 3.2 to3.4). These undissolved axitinib particles may create erroneously highconcentrations in tissue samples due to preferential dissolution in theorganic solvent used for extraction prior to LC-MS/MS analysis.Therefore, it might have been possible that tissue concentrations ofaxitinib after hydrogel degradation were elevated due the presence ofundissolved axitinib particles contaminating the tissue samples due toeither migration near tissues or contamination during tissue dissection.The solubility of axitinib in biorelevant media (PBS, pH 7.2 at 37° C.;Lorget et al., 2016; Characterization of the pH and temperature in therabbit, pig, and monkey eye: key parameters for the development oflong-acting delivery ocular strategies. Molecular pharmaceutics, 13(9),pp. 2891-2896) was determined to be approximately 0.5 μg/mL and anytissue values markedly higher than this potentially indicated eithertissue accumulation and/or dissolution of axitinib particles in theorganic solvent during extraction. However, in general, measured oculartissue levels of axitinib correlated well with the visual presence orabsence based on IR imaging (FIGS. 7A, 9, and 10).

The aim of the study was to demonstrate axitinib concentrations in thedesired target tissues (choroid/RPE, retina, and vitreous humor) wellabove the IC50 for the targeted tyrosine kinase receptors (Gross-Goupilet al., Clinical Medicine Insights: Oncology, 2013, 7:269-277) and abovethe half maximal effective concentration (EC50) of free axitinib forinhibition of ocular angiogenesis in a neonatal rat model asinvestigated in support of INLYTA® (INLYTA® AusPAR 2013, NDA 202324;Table 12) for all doses administered in order to validate efficient drugrelease.

TABLE 12 IC₅₀ values of axitinib for binding to vascular endothelialgrowth factor receptor 2 (VEGFR2), platelet-derived growth factorreceptor β (PDGFR-β), and stem cell growth factor receptor/type IIIreceptor tyrosine kinase (c-Kit), as well as EC₅₀ value of axitinib forinhibition of ocular angiogenesis in a rat model. EC₅₀ IC₅₀ Rat OcularVEGFR2 PDGFR-β c-Kit Angiogenesis Model 0.08 ng/mL 0.62 ng/mL 0.66 ng/mL0.19 ng/mL (0.2 nM) (1.6 nM) (1.7 nM)

Ocular Tissue Distribution in Group 1 (1 Implant, 109 μg Axitinib)

Ocular tissue concentrations for indicated time points are presented inTable 13.

TABLE 13 Ocular tissue distribution of axitinib released from 1 implantwith an axitinib dose of 109 μg axitinib. Axitinib concentrations in AH,VH (soluble part), retina, and choroid/RPE are presented in dependenceof the analysis time- points as average (mean) including standarddeviation, coefficient of variation (CV) as well as the confidenceinterval (CI) of the mean. In addition, minimum, median, and maximumvalues for each data point are presented. Time N Std 95% Tissue MonthsEyes Average Min Median Max Dev CV CI AH 1 day 4 0.5 0.0 0.5 0.9 0.4 75%0.4 (ng/mL) 1.5 3 2.7 0.8 1.5 5.9 2.8 102%  3.1 3 3 1.0 0.4 0.5 2.0 0.989% 1.0 4.5 4 0.7 0.6 0.7 1.0 0.2 23% 0.2 6 4 0.2 0.0 0.2 0.6 0.3 112% 0.2 7.5 3 0.0 0.0 0.0 0.0 0.0 n.a. n.a. 9 3 0.0 0.0 0.0 0.1 0.1 173% 0.1 VH 1 day 4 93.2 25.6 32.6 282.0 125.9 135%  123.4 (ng/mL) 1.5 3 23.112.9 15.1 41.3 15.8 68% 17.9 3 3 52.1 20.3 26.0 110.0 50.2 96% 56.8 4.54 115.8 58.4 89.8 225.0 77.6 67% 76.0 6 4 296.0 85.0 264.0 571.0 209.871% 205.6 7.5 3 184.9 2.9 21.7 530.0 299.0 162%  338.4 9 3 30.0 2.9 30.856.2 26.7 89% 30.2 Retina 1 day 4 184.7 116.0 147.4 328.1 97.7 53% 95.7(ng/g) 1.5 3 165.5 69.0 169.9 257.6 94.4 57% 106.8 3 3 176.8 120.2 203.3207.0 49.1 28% 55.5 4.5 4 271.8 153.0 206.0 522.1 170.3 63% 166.9 6 4150.0 18.8 147.1 287.0 120.7 80% 118.2 7.5 3 15.3 13.6 14.6 17.7 2.1 14%2.4 9 3 13.6 9.6 10.3 20.8 6.3 46% 7.1 Choroid/RPE 1 day 4 124.3 78.5119.6 179.6 48.4 39% 47.5 (ng/g) 1.5 3 256.6 128.1 278.7 363.0 119.0 46%134.7 3 3 328.2 96.6 306.5 581.6 243.2 74% 275.2 4.5 4 283.3 188.8 232.4479.5 133.1 47% 130.5 6 4 95.0 52.0 98.4 131.0 32.6 34% 31.9 7.5 3 35.018.7 33.3 52.9 17.2 49% 19.4 9 3 34.8 15.2 22.8 66.3 27.6 79% 31.2

Concentrations of axitinib in AH samples over the study duration wereconsidered low relative to the concentrations observed in the VH, retinaand choroid indicating a low level of axitinib migration towards theanterior chamber from the posterior chamber.

Median axitinib concentrations of soluble axitinib in VH samples overthe study duration were maximal (264.0 ng/mL) at 6 months. Individualsamples ranged from a minimum of 2.9 ng/mL (7.5 and 9 months) to amaximum of 571.0 ng/mL (6 months). Maximum values were similar to thesolubility limit of axitinib in biorelevant media, verifying that noundissolved axitinib disturbed the measurements.

Median axitinib concentrations in the retina were similar from day 1(147.4 ng/g) through 6 months (147.1 ng/g) prior to a noted decreasedown to 14.6 ng/g at 7.5 months. This indicates rapid and sustainedtransport of axitinib to the targeted retina tissues from the implantwithin 1 day of administration through approximately 6 months. Axitinibconcentrations decreased approximately 10-fold from 6 to 7.5 months inthe retinal tissue samples (147.1 to 14.6 ng/g). The average medianaxitinib concentration through 6 months was 175 ng/g in the retina whichwas well above the IC50 values for VEGFR2, PDGFR-β and c-Kit (2184, 282and 265-fold, respectively) and therefore at concentrations expected toinhibit neovascularization.

Median axitinib concentrations in the choroid/RPE were similar from day1 (119.6 ng/g) through 6 months (98.4 ng/g). This indicates rapid andsustained transport of axitinib to the tissues in the back of the eye bythe implant within 1 day of administration through approximately 6months. Axitinib concentrations decreased approximately 3-fold from 6 to7.5 months in the choroid/RPE tissue samples (98.4 to 33.3 ng/g). Theaverage median axitinib concentration through 6 months was 207 ng/g inthe choroid/RPE which was well above the IC50 values for VEGFR2, PDGFR-βand c-Kit (2589, 334 and 314-fold, respectively) and therefore atconcentrations expected to inhibit neovascularization.

Ocular Tissue Distribution in Group 2 (1 Implant, 227 μg Axitinib)

Ocular tissue concentrations for indicated time points are presented inTable 14.

TABLE 14 Ocular tissue distribution of axitinib released from 1 implantwith an axitinib dose of 227 μg axitinib. Axitinib concentrations in AH,VH (soluble part), retina, and choroid/RPE are presented in dependenceof the analysis time-points as average (mean) including standarddeviation, coefficient of variation (CV) as well as the confidenceinterval (CI) of the mean. In addition, minimum, median, and maximumvalues for each data point are presented. N Std CV 95% Tissue MonthsEyes Average Min Median Max Dev % CI AH 1 12 8.2 0.0 0.0 69.9 20.4 24711.5 (ng/mL) 3 18 0.0 0.0 0.0 0.4 0.1 424 0.0 6 12 0.0 0.0 0.0 0.1 0.0123 0.0 7 6 0.0 0.0 0.0 0.1 0.0 93 0.0 VH 1 12 4829 33 327 36400 11113230 6288 (ng/mL) 3 18 36430 48 614 610984 143547 394 66314 6 12 9765 555255 34355 10256 105 5803 7 6 8667 61 2105 41000 15971 184 12779 Retina1 12 852 124 315 5080 1415 166 801 (ng/g) 3 18 1466 124 378 13990 3259222 1505 6 12 21152 228 4957 154000 43428 205 24571 7 6 54121 131 13520264000 103849 192 83095 Choroid/RPE 1 12 753 131 332 4920 1352 179 765(ng/g) 3 16 7214 0 240 60800 17708 245 8677 6 12 1918 23 232 10100 3201167 1811 7 6 3497 0 1772 10400 4265 122 3413

Axitinib concentrations were low in the AH with median values of 0.0ng/mL through study completion (7 months) indicating little migration ofaxitinib from the posterior chamber to the anterior chamber.

The axitinib concentration in the VH represents the soluble axitinibthat was dissolved in the VH. The median values at 1 and 3 months, priorto hydrogel degradation, were similar to the determined solubility limitof axitinib in in PBS, pH 7.2 at 37° C. (0.4 to 0.5 μg/mL). The highmedian values at 6 and 7 months likely reflected contamination of VHsamples with undissolved axitinib particles that were solubilized duringextraction.

The median axitinib concentrations at 1 and 3 months in the retina weresimilar to the solubility limit of axitinib. The average median axitinibconcentration over the first three months was 341 ng/g in the retinawhich was well above the IC50 values for VEGFR2, PDGFR-β and c-Kit(4264, 569 and 487-fold, respectively) and therefore at concentrationsexpected to inhibit neovascularization. Similarly to the VH values, themedian values at 6 and 7 months likely reflected contamination of retinasamples with undissolved axitinib particles that were solubilized duringextraction.

The median axitinib concentrations at 1, 3 and 6 months in thechoroid/RPE tissue were similar to the solubility of axitinib. Theaverage median axitinib concentration over the first six months was 274ng/g in the choroid/RPE which was well above the IC50 values for VEGFR2,PDGFR-β and c-Kit (3426, 457 and 391-fold, respectively) and thereforeat concentrations expected to inhibit neovascularization. Similarly toVH and retina values, the median values at 7 months likely reflectedcontamination of choroid samples with undissolved axitinib particlesthat were solubilized during extraction.

Although the axitinib concentrations at 6 and/or 7 months likelyreflected contamination with undissolved axitinib, it was clearlydemonstrated that the implant site provided a sustained release ofaxitinib over the duration of the study.

Ocular Tissue Distribution in Groups 3 and 4 (2 Implants, Total Dose of290 μg Axitinib with or without Avastin®)

Ocular tissue concentrations for indicated time points are presented inTable 15.

TABLE 15 Ocular tissue distribution of axitinib released from 2 implantswith a total axitinib dose of 290 μg axitinib either without (group 3)or with (group 4) Avastin ®. Axitinib concentrations in AH, VH (solublepart), retina, and choroid/RPE are presented in dependence of theanalysis time-points as average (mean) including standard deviation,coefficient of variation (CV) as well as the confidence interval (CI) ofthe mean. In addition, minimum, median, and maximum values for each datapoint are presented. (G = group; Av. = Average) Time N CV 95% Tissue GMonths Eyes Av. Min Median Max SD % CI AH 3 0.5 6 0.2 0.0 0.1 0.6 0.2 960.2 (ng/mL) 1 6 0.1 0.0 0.0 0.1 0.1 110 0.0 3 6 0.1 0.0 0.0 0.2 0.1 1180.1 6 6 0.0 0.0 0.0 0.2 0.1 150 0.1 9 2 0.1 0.1 0.1 0.2 0.1 40 0.1 38 22.4 0.0 2.4 4.8 3.4 141 4.7 4 0.5 6 0.8 0.3 0.6 2.1 0.7 88 0.5 1 6 0.10.0 0.1 0.4 0.2 110 0.1 3 6 0.1 0.0 0.0 0.2 0.1 127 0.1 6 6 0.2 0.0 0.20.3 0.1 86 0.1 9 2 0.2 0.2 0.2 0.2 0.0 2 0.0 38 2 0.2 0.0 0.2 0.4 0.3141 0.4 VH 3 0.5 6 642 149 553 1390 412 64 330 (ng/mL) 1 6 95 22 71 24286 90 68 3 6 1869 50 277 6310 2720 146 2176 6 6 41 26 40 56 13 32 10 9 276 125 198 271 103 136 143 38 2 2 0 2 3 2 141 3 4 0.5 6 361 51 328 710287 80 230 1 6 232 61 170 705 240 103 192 3 6 1959 33 672 5370 2517 1282014 6 6 79 32 48 173 62 79 50 9 2 53 20 78 135 81 152 112 38 2 29 4 2954 35 124 49 Retina 3 0.5 6 185 5 94 688 257 139 205 (ng/g) 1 6 240 4099 622 261 109 209 3 6 9288 175 369 51000 20479 220 16386 6 6 1126 73623 4190 1567 139 1254 9 2 80 52 183 313 184 232 256 38 2 28 0 28 55 39141 54 4 0.5 5 118 39 91 302 106 90 93 1 6 205 70 144 448 153 75 123 3 66186 189 688 33700 13492 218 10796 6 6 4762 954 4255 10500 3299 69 26399 2 2068 136 4108 8080 5617 272 7785 38 2 28 21 28 36 11 38 15Choroid/RPE 3 0.5 6 237 90 192 434 153 65 122 (ng/g) 1 6 1103 48 1145700 2260 205 1808 3 6 4631 76 656 16600 6926 150 5542 6 6 17582 1395940 81500 31603 180 25287 9 2 27748 335 83168 166000 117143 422 16234938 2 19 0 19 39 27 141 38 4 0.5 6 1004 37 210 4940 1937 193 1550 1 62081 87 1608 5360 2112 101 1690 3 6 8399 363 6010 20300 8523 101 6820 66 17673 6740 11800 49000 15651 89 12523 9 2 7224 5080 14390 23700 13166182 18247 38 2 57 17 57 98 58 100 80

An Avastin® dose of 1.25 mg has a half-life of 6.6 days in rabbits(Sinapis et al., 2011; Pharmacokinetics of intravitreal bevacizumab(Avastin®) in rabbits. Clinical ophthalmology (Auckland, NZ), 5, p. 697)and by 1 month the mass remaining approximates 0.05 mg. In line withthat, the earliest time-point of 0.5 months demonstrated no obviousdifference in ocular tissue concentrations between groups 3 and 4indicating similar drug release when Avastin® concentration would beexpected to be highest in the VH in the rabbit model.

Axitinib concentrations in both groups were low in the AH with medianvalues of 0.2 ng/mL or less through study completion indicating littlemigration of axitinib from the posterior chamber to the anteriorchamber. With the exception of one value at 38 months, the others were<1 ng/mL for the study duration.

The axitinib concentration in the VH is the soluble axitinib that isdissolved in the VH. Median maximal concentrations in the VH were 553ng/mL in group 3 and 672 ng/mL in group 4. These values were similar tothe determined solubility limit of axitinib in biorelevant media. Medianconcentrations through 9 months demonstrated sustained release ofaxitinib from the implants in both groups. Axitinib was detected in theVH even at 38 months.

In group 3, the axitinib median concentrations in the retina tissue weremaximal at 6 months (623 ng/g) and ranged from 94 to 623 ng/g between0.5 to 9 months. Concentrations were less (28 ng/g) at 38 months, butstill at a biologically effective concentration. The average medianaxitinib concentration over the first three months was 184 ng/g in theretina which was well above the IC50 values for VEGFR2, PDGFR-β andc-Kit (2300, 307 and 263-fold, respectively) and therefore atconcentrations expected to inhibit neovascularization. In group 4, thevalues were comparable to group 3 through 3 months, but levels werehigher at 6 and 9 months and likely reflected contamination withundissolved axitinib particles that were solubilized during extraction.The retina tissue axitinib concentrations at 38 months were comparablebetween groups 2 and 3.

In group 3, the average median axitinib concentration over the firstthree months was 231 ng/g in the choroid/RPE tissue which was well abovethe IC50 values for VEGFR2, PDGFR-β and c-Kit (2888, 386 and 330-fold,respectively) and therefore at concentrations expected to inhibitneovascularization. The median values at 6 and 9 months likely reflectedcontamination with undissolved axitinib particles that were solubilizedduring extraction. Concentrations of axitinib in the choroid/RPE wereless (19 ng/g) at 38 months, but still at biologically effectiveconcentration. In group 4, axitinib concentrations in the choroid/RPEwere similar compared to group 3 at 0.5 months but were much higher atthe later time-points. Considering the broad range seen between theminimum and maximum sample concentrations within each time-point, thehigher values likely reflected contamination with undissolved axitinibparticles that were solubilized during extraction.

Summary of the Ocular Distribution Data

Table 16 gives an overview of median axitinib concentrations observed inthe different tissues in all four groups in Dutch Belted rabbits.

TABLE 16 Axitinib concentration measured in samples from aqueous humor(AH), vitreous humor (VH), retina, and choroid/RPE dependent on theaxitinib dose (median value). Axitinib concentration (ng/mL or ng/g,respectively) was measured at indicated time points for the differentgroups using LC-MS/MS. Group 1 Group 2 Group 3 Group 4 1 Implant 1Implant 2 Implants 2 Implants + Avastin (109 μg axitinib) (227 μgaxitinib) (290 μg axitinib) (290 μg axitinib) Time Time Time Time Tissue(months) Median (months) Median (months) Median (months) Median AH 1 day0.5 1 0.0 0.5 0.1 0.5 0.6 (ng/mL) 1.5 1.5 3 0.0 1 0.0 1 0.1 3 0.5 6 0.03 0.0 3 0.0 4.5 0.7 7 0.0 6 0.0 6 0.2 6 0.2 — — 9 0.1 9 0.2 7.5 0.0 — —38 2.4 38 0.2 9 0.0 — — — — — — VH 1 day 33 1 327 0.5 553 0.5 328(ng/mL) 1.5 15 3 614 1 71 1 170 3 26 6 5255 3 277 3 672 4.5 90 7 2105 640 6 48 6 264 — — 9 198 9 78 7.5 22 — — 38 2 38 29 9 31 — — — — — —Retina 1 day 147 1 315 0.5 94 0.5 91 (ng/g) 1.5 170 3 378 1 99 1 144 3203 6 4957 3 369 3 688 4.5 206 7 13520 6 623 6 4255 6 147 — — 9 183 94108 7.5 15 — — 38 28 38 28 9 10 — — — — — — Choroid/RPE 1 day 120 1 3320.5 192 0.5 210 (ng/g) 1.5 279 3 240 1 114 1 1608 3 307 6 232 3 656 36010 4.5 232 7 1772 6 5940 6 11800 6 98 — — 9 83168 9 14390 7.5 33 — —38 19 38 57 9 23 — — — — — —

There was a dose-related increase in axitinib concentrations in thevitreous humor tissues for the mid (227 μg) and high dose (290 μg)compared to the low dose (109 μg). There was no dose-related differencein the targeted tissues of the retina and choroid prior to hydrogeldegradation. In addition, co-administration of Avastin® in group 4 didnot change drug release when compared to group 3. Even after 38 months,axitinib was present at doses above the IC50 and EC50 in the VH, retina,and choroid/RPE demonstrating sustained persistence. Axitinib was eithernot detected in the aqueous humor or was present only at lowconcentrations for all dose strengths through the duration of thestudies indicating a low level of axitinib migration towards theanterior chamber from the posterior chamber were the implants arelocalized.

Results: Axitinib Release Rate

In addition, also non-soluble axitinib in VH containing the implant wasassessed by LC-MS/MS analysis to determine the remaining amount ofaxitinib at sacrifice time points. The axitinib dose at the time ofadministration was determined by averaging values from ten implantsspiked into ten bovine VH samples.

In the low dose group (group 1, 109 μg axitinib) and intermediate dosegroup (group 2, 227 μg axitinib), non-soluble axitinib in VH containingthe implant was assessed by LC-MS/MS analysis to determine the remainingamount of axitinib at sacrifice time points. The remaining amount wasthen compared to the initial dose and the in vivo release rate over timewas calculated. The mean amount of axitinib released from the implantover 6 months in rabbits was estimated to be 0.52 μg/day. Followinghydrogel degradation, the rate of release appears to slow down as theaxitinib forms a localized structure. However, released axitinib levelswere still sufficient to inhibit vascular leakage (cf. Example 3.4).

Example 3.6: Acute Exposure to Axitinib Bolus Dose

In order to test acute exposure to axitinib particles, an intravitreal,bilateral bolus dose of a 600 μg (1.2%) suspension of axitinib inProVisc® (Alcon; 1% 2000 kDa sodium hyaluronate) was administered via a50 μL injection using a 27G thin wall needle syringe to Dutch beltrabbits (n=3 animals, 6 eyes).

At 1 month, rabbits were sacrificed and whole eyes were prepared forhistopathological analysis. The eyes were fixed, sectioned vertically in12 equal parts, stained with hematoxylin and eosin (H&E) and examined bya board certified veterinary pathologist. Histopathology assessments ateach time point included vitreous, retinal, scleral, or episcleralinflammation, retinal disruption and fibrosis around the injected area.Tissues were scored on a semi-quantitative scale from 0-5 for anyabnormalities, where 0 denotes no change (normal), 1 denotes rare fociof change (minimal), 2 denotes mild diffuse change or more pronouncedfocal change, 3 denotes moderate diffuse change, 4 denotes markeddiffuse change and 5 denotes severe diffuse change.

IOPs determined weekly remained within the normal range. Intravitrealbolus dosing of 600 μg of axitinib was generally tolerable (Table 17).No gross lesions were noted in any eyes. Minimal histiocytic andmultinucleated giant cell inflammation was observed around the axitinibinjection site. Mild focal retinal disruptions were observed in two eyesin proximity to the puncture location and considered procedure related.Minimal retinal disruption with a few macrophages in the photoreceptorlayer was observed in 1 of 6 eyes. Minimal retinal vacuolization wasobserved in numerous sections from 4 of 6 eyes. Minimal to mild chronicsubcorneal inflammation was observed in 4 of 6 eyes.

TABLE 17 Axitinib bolus histopathological study results. Results werescored on a scale of 0-5, where 0 denotes no change (normal), 1 denotesrare foci of change (minimal), 2 denotes mild diffuse change or morepronounced focal change, 3 denotes moderate diffuse change, 4 denotesmarked diffuse change and 5 denotes severe diffuse change. Results arepresented as mean and standard deviation (SD). Vitreous Retinal,Scleral, Fibrosis Chronic Retinal Retinal Chamber or Episcleral Aroundthe Subcorneal Result Disruption Vacuolization Inflammation InflammationArticle Inflammation Mean (SD) 0.10 (0.11) 0.50 (0.46) 0.23 (0.21) 0.03(0.05) 0.00 (0.00) 0.28 (0.38)

In summary, the bolus injection was well-tolerated and safe. Theinjected dose led to a higher acute localized axitinib dose percompartmental volume in rabbit eyes (1.3 mL/eye) as it would have led toin a human eye (4.5 mL/eye).

Example 4: Evaluation of Axitinib Implants in Beagle Dogs

In order to study the axitinib release from the implants in beagle dogs,12 dogs received each one implant per eye (bilaterally) with 109 μgaxitinib via intravitreal injection using a 27G ultra-thin wall needleto administer the implant. Formulation and dimensions of the implantsinjected are presented in Table 6 (implant type #5).

Prior to implant administration, animals were anesthetized with anintramuscular injection of ketamine hydrochloride (20 mg/kg) andxylazine (5 mg/kg). Eyes and the surrounding area were cleaned with a 5%Betadine solution and rinsed with balanced salt solution (BSS). One totwo drops of topical proparacaine hydrochloride anesthetic (0.5%) wasapplied. The eye was draped, and a sterile wire speculum was placed toretract the eyelids. The injection needle was placed approximately 3 to5 mm away from the limbus and deployed in a single stroke.

At predetermined sacrifice time points (3 animals each at 1.5, 3, 4.5,and 6 months post implant administration, respectively) the eyes werecollected, flash frozen, and then dissected and weighed for the targettissues of the choroid, retina, vitreous humor and aqueous humor. Plasmawas additionally collected at the selected time points. Axitinibconcentrations were assessed in AH, VH (soluble axitinib), choroid/RPE,and retina, as well as in plasma. In addition, also non-soluble axitinibin VH containing the implant was assessed by LC-MS/MS analysis todetermine the remaining amount of axitinib at sacrifice time points(methods described under Example 3.5).

All values in plasma were reported as below the LLOQ (0.05 ng/mL forboth isomers) indicating near absent systemic exposure to axitinib inbeagle dogs following implant administration (total administered dose of218 μg).

Pharmacokinetic data of axitinib concentrations in the target tissuesover the study duration are presented in Table 18. Concentrations ofaxitinib in beagle AH samples over 4.5 months were considered lowrelative to the concentrations observed in the VH, retina and choroidindicating a low level of axitinib migration towards the anteriorchamber from the posterior chamber prior to hydrogel degradation.Axitinib was present at higher concentrations in the AH at 6 months(after hydrogel degradation). This may have been due to migration ofundissolved axitinib particles released from the degraded hydrogeltowards the anterior chamber from the posterior chamber or due to samplecontamination of the AH by VH during tissue dissection. High axitinibconcentrations in the AH were never observed in any of the rabbitstudies.

Median axitinib concentrations in the VH were similar over the studyduration (range from 11.9 to 27.1 ng/mL). These values were similar tothat observed in the monkey study at a similar dose (138 μg; cf. Example5).

Median axitinib concentrations in the retina were similar over the studyduration (range from 15.4 to 31.0 ng/mL) indicating continuous sustaineddelivery of axitinib from the implant to retina tissues. The averagemedian axitinib concentration over six months was 23 ng/g in the retinawhich was well above the IC50 values for VEGFR2, PDGFR-β and c-Kit (288,37 and 35-fold, respectively) and therefore at concentrations expectedto inhibit neovascularization. In addition, this concentration was121-fold higher than the EC50 determined for free axitinib in the ocularangiogenesis neonatal rat model.

Median axitinib concentrations in the choroid/RPE were similar over thestudy duration (range from 16.2 to 39.8 ng/g) indicating sustaineddelivery of axitinib from the implant to the choroid tissues throughstudy completion. The average median axitinib concentration over sixmonths was 31 ng/g in the choroid/RPE which was well above the IC50values for VEGFR2, PDGFR-β and c-Kit (388, 50 and 47-fold, respectively)and therefore at concentrations expected to inhibit neovascularization.In addition, this concentration was 163-fold higher than the EC50determined for free axitinib in the ocular angiogenesis neonatal ratmodel.

TABLE 18 Pharmacokinetic study results in beagle dogs. Axitinibconcentrations in AH, VH (soluble part), retina, and choroid/RPE arepresented in dependence of the analysis time-points as average (mean)including standard deviation, coefficient of variation (CV) as well asthe confidence interval (CI) of the mean. In addition, minimum, median,and maximum values for each data point are presented. Time N Std 95%Tissue Months Eyes Average Min Median Max Dev CV CI AH 1.5 4 2.8 0.4 3.14.6 2.1 76 2.0 (ng/mL) 3 6 1.2 0.1 0.9 3.2 1.1 87 0.8 4.5 5 0.6 0.5 0.60.9 0.1 22 0.1 6 6 66.4 0.5 14.5 228.0 94.9 143 76.0 VH 1.5 4 26.8 20.727.1 32.5 5.5 20 5.4 (ng/mL) 3 6 19.4 16.5 18.4 23.3 2.5 13 2.0 4.5 510.1 1.8 11.9 18.1 6.5 64 5.7 6 6 33.6 0.9 17.2 84.3 36.3 108 29.1Retina 1.5 4 27.6 22.2 23.9 40.6 8.7 32% 8.5 (ng/g) 3 6 30.8 18.7 31.039.2 7.8 25% 6.2 4.5 5 52.3 8.6 20.4 134.0 56.5 108%  49.5 6 6 16.2 1.915.4 35.2 11.4 70% 9.1 Choroid/RPE 1.5 4 35.7 13.5 29.3 70.8 24.6 69%24.1 (ng/g) 3 6 29.5 8.3 16.2 87.8 29.9 101%  24.0 4.5 5 62.1 9.5 39.8126.0 48.0 77% 42.1 6 6 72.9 5.9 38.2 250.0 90.6 124%  72.5

The mean amount of axitinib released from the implant over 6 months inbeagle dogs was estimated to be approximately 0.52 μg/day (Table 19),similar to the release rates seen in rabbits with the same dose (cf.Example 3.5). The axitinib dose at the time of administration wasdetermined by averaging values from ten implants spiked into ten bovineVH samples.

TABLE 19 Non-soluble axitinib in VH containing the implant. Baselinevalues refer to the axitinib amount in the implants prior toadministration. Std Time Average Min Median Max. Dev 95% Months N (μg)(μg) (μg) (μg) (μg) CV CI Baseline 10 109 95 110 119 7  6% 4 1.5 4 75 7276 77 2  3% 2 3 6 50 28 54 59 11 23% 9 4.5 5 42 0 49 67 26 62% 23 6 6 150 13 39 16 104%  13

Example 5: Evaluation of Axitinib Implants in Non-Human Primates

In order to study safety and drug release in African green monkeys,animals received one implant in either the right or left eye (for drugrelease studies) or bilaterally (for safety and tolerability studies)via intravitreal injection using a 27G ultra-thin wall needle, theimplant comprising an axitinib dose of 138 μg. Formulation anddimensions of the implants injected are presented in Table 6 (implanttype #4).

Prior to implant administration, animals were anesthetized with anintramuscular injection of ketamine hydrochloride (20 mg/kg) andxylazine (5 mg/kg). Eyes and the surrounding area were cleaned with a 5%Betadine solution and rinsed with balanced salt solution (BSS). One totwo drops of topical proparacaine hydrochloride anesthetic (0.5%) wasapplied. The eye was draped, and a sterile wire speculum was placed toretract the eyelids. The injection needle was placed approximately 3 to5 mm away from the limbus and deployed in a single stroke.

Drug Release

To evaluate drug release, 6 monkeys were sacrificed 3 months afterimplant administration and the eyes were collected, flash frozen, andthen dissected and weighed for target tissues of the choroid, retina,vitreous humor and aqueous humor. Serum was additionally collected atthe selected time point. Subsequent analysis following axitinibextraction from tissues (where necessary) and dilution was performed,followed by LC-MS/MS for the determination of axitinib concentrations inthe samples (methods described under Example 3.5).

Pharmacokinetic data of median axitinib concentrations in the targettissues is presented in Table 20. As observed for rabbits and beagledogs, axitinib concentrations in the AH were low indicating littlemovement of axitinib from the posterior to the anterior chamber in themonkey eye. Soluble axitinib concentrations in the VH were low (12ng/mL) compared to those observed in rabbits, but they were similar toconcentrations observed in beagle dogs.

The average median axitinib concentration over the three months was 39ng/g in the retina which was well above the IC50 values for VEGFR2,PDGFR-δ and c-Kit (488, 63 and 59-fold, respectively) and therefore atconcentrations expected to inhibit neovascularization. In addition, thisconcentration was 205-fold higher than the half-maximal effectiveconcentration (EC50=0.19 ng/mL) determined for free axitinib in theocular angiogenesis neonatal rat model.

The average median axitinib concentration over the three months was 940ng/g in the choroid/RPE tissue which was well above the IC50 values forVEGFR2, PDGFR-β and c-Kit (11750, 1516 and 1424-fold, respectively) andtherefore at concentrations expected to inhibit neovascularization. Inaddition, this concentration was 4947-fold higher than the EC50determined for free axitinib in the ocular angiogenesis neonatal ratmodel.

The choroid/RPE axitinib concentration at 3 months was significantlyhigher in monkeys (940 ng/g) compared to rabbits (240, 656, and 307ng/g, respectively) and beagle dogs (16 ng/g). As axitinib was found tobind to melanin in the uveal tract of the eye in mice (INLYTA® support,NDA202324), this might be due to an increased ocular melanin content inthe central and peripheral choroid/RPE compared to rabbits and beagles(Durairaj et al., 2012, Intraocular distribution of melanin in human,monkey, rabbit, minipig, and dog eyes. Experimental eye research, 98,pp. 23-27). In addition, also varying vitreous volumes may havecontributed to differences observed in tissue concentrations (Dutchbelted rabbit=1.3 mL, beagle dog=2.2 mL, and African green monkey=2.4mL; Glogowski et al., 2012, Journal of ocular pharmacology andtherapeutics, 28 (3), pp. 290-298; Struble et al., 2014, ActaOphthalmologica, 92).

Moreover, the systemic exposure to axitinib in serum from the implantwas below the LLOQ (0.088 ng/mL for trans-axitinib and 0.012 ng/mL forcis-axitinib).

TABLE 20 Pharmacokinetic study results in African green monkeys.Axitinib concentrations in AH, VH (soluble part), retina, andchoroid/RPE are presented in dependence of the analysis time-points asaverage (mean) including standard deviation, coefficient of variation(CV) as well as the confidence interval (CI) of the mean. In addition,minimum, median, and maximum values for each data point are presented.Time N Std 95% Tissue Months Eyes Average Min Median Max Dev CV CI AH 36 0.47 0.00 0.48 0.76 0.28 59% 0.22 (ng/mL) VH 3 6 16 4 12 37 12 73% 9(ng/mL) Retina 3 6 52 28 39 89 28 54% 22 (ng/g) Choroid/RPE 3 6 1107 568940 1980 417 38% 193 (ng/g)

Safety and Tolerability

To evaluate safety and tolerability, the 6 monkeys were monitored for 3months post implant administration. Ocular examination was performed viaophthalmic slit-lamp examination and graded according to the modifiedHackett-McDonald scoring system. Ocular examination revealed no notablefindings, including no intraocular inflammation or retinal changes overthe study duration. No changes in IOP or pupil diameter occurred overthe study duration.

Conclusions from Pre-Clinical Animal Studies

In summary, pharmacokinetic results demonstrate levels of axitinib inthe relevant ocular tissues (VH, Retina, Choroid/RPE) delivered from theimplants significantly above the IC50 for tyrosine kinases and the EC50for inhibition of angiogenesis in a rat model (Table 12) in all animalsexamined (dog, beagle, monkey) over a duration of up to 38 months. Ingeneral, measured ocular tissue levels of axitinib correlated with thevisual presence or absence of the implants and the drug in the posteriorchamber based on IR imaging. In contrast, axitinib concentrations in theAH were either absent or very low compared to VH, retina, andchoroid/RPE verifying that only a low level of axitinib migrationtowards the anterior chamber from the posterior chamber were theimplants are localized occurred in all three animal species. However,the drug release in humans may differ from non-clinical studies due tocomparative differences between animals and humans with respect tovitreous volumes, vitreous viscosities, and drug clearance rates thatdirectly relate to the surface area of the retinal pigment epithelium(RPE) for small molecules.

All animal studies demonstrated that levels in plasma/serum were belowthe LLOQ indicating near absent systemic exposure to axitinib.Therefore, the plasma/serum levels resulting from implants of thepresent application were much lower than serum levels reported in theliterature for INLYTA®. Because axitinib has no subsequent distributionoutside of the intraocular compartment, any drug-drug interaction riskcan be considered minimal.

Imaging analysis by IR demonstrated visual biodegradation of thehydrogel in the posterior chamber over time leading to completedegradation after approximately 6 months. Axitinib drug particlesremaining at the former implant locations formed a monolithic structurecontinuing to release axitinib at levels sufficient for sustainedinhibition of vascular leakage. Efficacy in suppression of vascularleakage was demonstrated out to 6 and 21 months in rabbit VEGF challengestudies. Co-administration of bevacizumab resulted in an even more rapidinhibition of vascular leakage in the first 3 months when compared toadministration of the axitinib implants alone.

Taken together, the data demonstrate that the axitinib implants of thepresent invention are safe and well-tolerated as well as show sufficientdrug-release and good efficacy in rabbits, dogs, and African green monkeys.

Example 6: Human Clinical Trials with Axitinib Implants

The axitinib implants of the present application were examined in humansin a next step. The axitinib implants are applied in order to reducechoroidal/retinal neovascularization and exudation, decrease vascularpermeability, decrease (or essentially maintain or prevent a clinicallysignificant increase of) central subfield thickness, while in certainembodiments not impairing or even improving visual acuity. As theimplants provide sustained release of axitinib and thus a prolongedprovision of axitinib to the vitreous humor and the surrounding tissue,treatment with the implants of the present application reduces theburden on patients and caregivers, as well as the risk of adverseeffects associated with frequent injections of anti-VEGF therapeutics.

Subjects with neovascular age-related macular degeneration (wet AMD) whohad retinal fluid were enrolled in an open-label, dose-escalation studyto evaluate safety, tolerability and efficacy of the axitinib implantsof the present invention in human subjects. Patients were naïve ornon-naïve to treat

Example 6.1: Formulations

Tables 21.1 and 21.2 give an overview of formulations and dimensions ofimplants containing about 200 μg and about 600 μg axitinib, some ofwhich are applied in human clinical trials (or are planned or suitableto be applied in future human clinical trials). The dimension of theimplants in the dry state were measured after the implants had beenproduced and had been dried and just before they were loaded into theneedles. The implants remained in an inert glove box kept below 20 ppmof both oxygen and moisture for at least about 7 days prior topackaging. The dimensions of hydrated implants indicated in these tableswere measured after 24 hours in biorelevant media (PBS, pH 7.2 at 37°C.).

Measurement of the implant dimensions (both in the dry and in the wetstate) were performed by a custom 3-camera Keyence Inspection System. 2Cameras were used to measure the diameter with a tolerance of ±0.002 mm(of all datapoints acquired, the average (=mean) value is recorded), and1 camera was used to measure the length with a tolerance of ±0.04 mm (ofseveral datapoints, the longest measured length is recorded).

TABLE 21.1 Formulation, configuration and dimensions of an implant withan axitinib dose of about 200 μg that was used in the clinical studiesreported in Example 6.3 and 6.4.. Implant type Implant #1 FormulationAxitinib 49.4%  (% dry Dose (200 μg) basis w/w) PEG Hydrogel 42.0% 4a20K PEG-SAZ  28% 8a20K PEG-NH2  14% Sodium phosphate 8.6% FormulationAxitinib 7.5% (% wet PEG Hydrogel 6.9% basis w/w) 4a20K PEG-SAZ 4.6%8a20K PEG-NH2 2.3% Sodium phosphate 1.5% WFI 84.1%  Axitinib per final12.1 μg/mm dry length Approximate 423    Implant Mass (dose μg/API %)Configuration Stretching Method Dry (Stretch Factor) (4.5) Needle Size27G TW 1.25″ (0.27 mm ID) Injector/Syringe Implant Injector PackagingFoil Pouches Sterilization Type Gamma Site Storage RefrigeratedDimensions Dried Diameter 0.24 ± 0.013 mm Length 16.5 ± 0.26 mm Volume0.75 ± 0.08 mm³ Implant Mass 0.45 mg Axitinib per volume 266.7  (μg/mm³) Hydrated Diameter 0.75 mm Length 7.5 mm Ratio of diameter 3.13(hydrated) to diameter (dry) Ratio of length (dry) 2.20 to length(hydrated)

TABLE 21.2 Formulations, configurations and dimensions of implants withaxitinib doses of about 600 μg. Implant type Implant #2 Implant #3Implant #4 Formulation Axitinib 49.8%  68.6% 68.6% (% dry Dose (600 μg)(600 μg) (600 μg) basis w/w) PEG Hydrogel 42.0%  26.0% 26.0% 4a20KPEG-SAZ  28% 17.4% 17.4% 8a20K PEG-NH2  14% 8.7% 8.7% Sodium phosphate8.2% 5.4% 5.4% Formulation Axitinib 12.0%  16.5% 16.5% (% wet PEGHydrogel 6.3% 6.3% 6.3% basis w/w) 4a20K PEG-SAZ 4.2% 4.2% 4.2% 8a20KPEG-NH2 2.1% 2.1% 2.1% Sodium phosphate 1.3% 1.3% 1.3% WFI 80.4%  75.9%75.9% Axitinib per final 71.4 μg/mm 71.4 μg/mm 81.1 μg/mm dry lengthApproximate 1205     875 875 Implant Mass (dose ug/API %) ConfigurationStretching Method Wet Wet Wet (Stretch Factor) (2.1) (2.1) (2.1) NeedleSize 25G UTW 1″ 25G UTW 1″ 25G UTW 0.5″ (0.4 mm ID) (0.4 mm ID) (0.4 mmID) Injector/Syringe Implant Injector Implant Injector Implant InjectorPackaging Foil Pouches Foil Pouches Foil Pouches Sterilization TypeGamma Gamma Gamma Site Storage Refrigerated Refrigerated RefrigeratedDimensions Dried Diameter 0.36 mm 0.37 ± 0.014 mm 0.37 ± 0.008 mm Length8.4 mm 8.4 ±0.04 mm 7.4 ± 0.03 mm Volume 0.86 mm³ 0.90 ± 0.07 mm³ 0.81 ±0.05 mm³ Implant Mass 1.20 mg 0.95 ±0.04 mg 0.95 ± 0.01 mg Axitinib pervolume 697.7   666.7 740.7 (μg/mm³) Hydrated Diameter 0.7 mm 0.68 mm0.77 mm Length 10 mm 8.23 mm 6.8 mm Ratio of diameter 1.94 1.84 2.08(hydrated) to diameter (dry) Ratio of length (dry) 0.84 1.02 1.09 tolength (hydrated)

The 200 μg implant of Table 21.1 and used in the clinical study furtherdescribed below was also investigated for axitinib release in the invitro real time and accelerated assays (assays as described in Example2). The in vitro real-time data suggest complete axitinib release after225 days, while accelerated release is complete after around 2 weeks(FIG. 14).

Example 6.2: Details of Clinical Study

The clinical study using the 200 μg implant (Implant #1 of Table 21.1above) was conducted in accordance with the study protocol, which isreproduced in the following (although the study has already begun andparts of it have already been performed, and the results are reported inExample 6.3 and 6.4 herein, as is common for study protocols, the studyprotocol is nevertheless written in the present and future tense). Theimplant referred to in the study protocol as “OTX-TKI” is Implant #1 ofTable 21.1, above. Depending on the dose, one (dose of 200 μg), two(dose of 400 μg) or three (dose of 600 μg) implants are administeredconcurrently as described herein. Any abbreviations used in thefollowing study protocol as well as Appendices A to G mentioned hereinare provided at the end of the study protocol (i.e., at the end ofExample 6.2).

Study Objective

The primary study objective is to evaluate the safety, tolerability andefficacy of OTX-TKI (axitinib implant) for intravitreal use, in subjectswho have neovascular age-related macular degeneration (nvAMD).

Study Design

This is a multi-center, open label, dose escalation, Phase 1 safetystudy. This safety study will enroll approximately 26 subjects atapproximately 5 sites in Australia. Three cohorts will be evaluatedduring this study: 200 μg (Cohort 1) and 400 μg (Cohort 2) dose groupsfollowed by a third cohort (Cohort 3) consisting of two differenttreatment groups designed to test monotherapy (6 subjects receiving 600μg OTX-TKI) and combination therapy with anti-VEGF (6 subjects treatedwith 400 μg OTX-TKI along with a single anti-VEGF injection). Safetydata from subjects treated in Cohorts 1 and 2 will be evaluated by theDSMC prior to the initiation of the next cohort. The study will lastapproximately 9 months; there will be a screening/baseline visitfollowed by the injection day visit, with approximately 10 additionalvisits (See Appendix A).

The screening visit (Visit 1) may take place up to 14 days prior to theInjection Visit (Visit 2; Day 1). At Visit 2, subjects will have theOTX-TKI implant(s) injected (for Cohort 3, injections of the OTX-TKIimplants and anti-VEGF may be spaced out over 1-4 weeks at theInvestigator's discretion). Subjects will return for follow-up visit 2-3days later for post-operative evaluation at Visit 3. Subjects will thenreturn in approximately one week (Visit 4) and then again atapproximately two weeks (Visit 5) for safety evaluations. Followingthat, subjects will return for safety evaluations on: Visit 6 (Month 1),Visit 7 (Month 2), Visit 8 (Month 3), Visit 9 (Month 4.5), Visit 10(Month 6), Visit 11 (Month 7.5) and Visit 12 (Month 9) for final safetyevaluations, and to be discharged from the study. At the Investigator'sdiscretion, subjects who still have evidence of biological activity atMonth 9 should be followed monthly until the CNV leakage has returned tobaseline levels or until the Investigator believes the subject isclinically stable.

Cohort 1 is planned to comprise 6 subjects. They will each receive one200 μg implant per eye which is estimated to provide an approximate drugdelivery of about 7 μg per week.

Cohort 2 is planned to comprise 6 to 8 subjects. They will each receivetwo 200 μg implants per eye which together are estimated to provide anapproximate drug delivery of about 14 μg per week.

Cohort 3a (monotherapy) is planned to comprise 6 subjects. They willeach receive three 200 μg implants per eye which together are estimatedto provide an approximate drug delivery of about 21 μg per week.

Cohort 3b (combination treatment therapy) is planned to comprise 6subjects. They will each receive two 200 μg implants per eye whichtogether are estimated to provide an approximate drug delivery of about14 μg per week plus a single dose of an anti-VEGF agent.

Cohort 1 will be fully enrolled and all safety and tolerability data ofOTX-TKI for each subject (minimum follow up data for two weeks) will beassessed prior to any subject entering the next cohort. The same processwill be repeated for Cohort 2. Dose escalation to the next cohort willbe based on the recommendation of the DSMC and confirmed by the MM.

If one DLT is identified in Cohorts 1, 2, or 3a, enrollment willcontinue until the cohort has been fully enrolled. If a second DLT isseen in Cohorts 1, 2, or 3a, enrollment will stop. If a second DLT isseen in Cohort 3a, enrollment in that cohort will stop and the previouslower dose will be declared the MTD.

In addition to safety and tolerability evaluations, this first clinicalstudy will also determine if there is any evidence of biologicalactivity by assessing changes in central subfield thickness (CSFT), FAand BCVA over time compared with baseline evaluations.

Subjects can have only 1 eye treated with OTX-TKI. The contralateraleye, if needed, will be treated at the Investigator's discretion. Thisshould be standard of care and in no case should another investigationaldrug be used for the contralateral eye.

If both eyes are eligible, the eye with the worst BCVA will be selectedas the study eye. If both eyes are eligible and both have the same BCVAthen the Investigator will determine which eye will be selected as thestudy eye.

Safety Outcome Measures

Safety will be assessed immediately following injection of the implant.During the immediate post-injection time subjects will be monitored forvisual acuity and elevated IOP.

The safety outcome measures will include an assessment of:

-   -   Incidence of treatment emergent ocular adverse events    -   Incidence of treatment emergent systemic adverse events    -   Vital signs    -   Ocular comfort score (to be assessed by subjects)    -   BCVA    -   Change in ocular examination compared to baseline assessment        (e.g., slit lamp biomicroscopy, fundus examination)    -   Anterior chamber cell and flare score    -   Vitreous cell and haze score    -   Clinically significant increases in IOP    -   Potential injection related complications (e.g.,        endophthalmitis, retinal detachment, etc.)    -   Growth or development of geography atrophy    -   Clinically significant change in safety laboratory values    -   Plasma sample for pharmacokinetic analysis will be taken at        Screening/Baseline Visit (Visit 1), Day 1 (Visit 2), Day 3        (Visit 3), and Month 3 (Visit 8).

Efficacy Outcome Measures

Efficacy measures will be observed throughout the conduct of the study.The efficacy outcome measures will include an assessment of:

-   -   Mean change in central subfield thickness (CSFT) from baseline        over time measured by SD-OCT at 6 months and all visits    -   Change in BCVA from baseline over time at 6 months and all        visits    -   Clinically significant change in leakage determined by FA and        OCT-A    -   A decrease in CSFT of 50 μm at each study visit compared to        baseline through Month 9    -   Absence of any SRF and IRF, both individually and together at        each study visit    -   Need for rescue therapy

Subject Selection—Study Population

The subjects enrolled in this study will have a diagnosis of primarysubfoveal (active sub- or juxtafoveal CNV with leakage involving thefovea) neovascularization (SFNV) secondary to AMD. Subjects withpredominantly classic, minimally classic or occult lesions will all beincluded.

If both eyes qualify (i.e., all inclusion and exclusion criteria aremet) then the eye with the worse BCVA will be the study eye. If botheyes qualify AND both eyes have the same BCVA, then the Investigatorwill determine which eye will be selected as the study eye.

Subject Selection—Inclusion Criteria

Individuals of either gender will be eligible for study participation ifthey:

-   1. Are at least 50 years of age-   2. Are eligible for standard therapy-   3. Have active primary CNVM secondary to AMD, either newly diagnosed    or previously treated with documented response to anti-VEGF therapy    in the study eye [primary subfoveal CNV secondary to AMD including    juxtafoveal lesions that affect the fovea] documented by FA and    SD-OCT-   4. Have a lesion area <30.5 mm² (12 disc areas) (measured according    to the protocol of the Macular Photocoagulation Study) in the study    eye-   5. Have a total area of CNV that is 50% of total lesion by    Fluorescein angiography (FA) and fundus photography in the study eye-   6. Have presence of foveal intraretinal or subretinal fluid with    CSFT>300 μm on SD-OCT in the study eye-   7. Have adequate ocular media and adequate pupillary dilation in the    study eye to permit good quality fundus imaging-   8. Have had an electrocardiogram within 12 weeks prior to Day 1 (day    of injection) that shows no clinically significant abnormalities-   9. Are female who is postmenopausal for at least 12 months prior to    screening or surgically sterile; or male or female of childbearing    potential willing to use two forms of adequate contraception from    screening until they exit the study-   10. Are able and willing to comply with all study requirements and    visits-   11. Have provided written informed consent.

Subject Selection—Exclusion Criteria

Individuals are not eligible for study participation if they:

-   1. Have monocular vision-   2. Have a scar, fibrosis or atrophy involving the center of the    fovea that is severe (mild fibrosis or atrophy is not exclusionary)    in the study eye-   3. Have evidence of a scar or fibrosis of >50% of the total lesion    in the study eye-   4. Have previous laser photocoagulation to the center of the fovea    in the study eye-   5. Have history of intraocular surgery including cataract surgery or    keratorefractive surgery (LASIK, PRK, etc.) or another treatment in    the study eye within 3 months of screening-   6. Aphakia in the study eye-   7. Have expectation of penetrating keratoplasty, vitrectomy,    cataract surgery, or LASIK or any other intraocular surgery during    the study period in the study eye-   8. Have a history of vitreoretinal surgery (including vitrectomy) or    other ocular surgeries including scleral buckle or glaucoma    filtering/shunt surgery in the study eye. Prior laser treatment,    other than for treatment of CNV is allowed-   9. Have a presence of a disease other than NV (wet) AMD in the study    eye that could affect vision or safety assessments-   10. Have a history of significant ocular infection (bacterial,    viral, or fungal) within the previous 3 months, or history of    herpetic ocular diseases (including herpes simplex virus, varicella    zoster or cytomegalovirus retinitis) or toxoplasmosis gondii or    chronic/recurrent inflammatory eye disease (i.e., scleritis,    uveitis, corneal edema) in either eye-   11. Have evidence of a rhegmatogenous retinal detachment or visually    significant epiretinal membrane (severe ERM), or macular hole, or    tear of the retinal pigment epithelium (RPE) in the macula in the    study eye-   12. Have proliferative diabetic retinopathy, branch retinal vein    occlusion or central retinal vein occlusion in the study eye-   13. Have a history of diabetic macular edema (DME) in the study eye-   14. Have a history of or presence of vitreous hemorrhage in the    study eye. Subject is still eligible if history of past hemorrhagic    PVD has resolved-   15. Have advanced glaucoma (uncontrolled IOP 25 mmHg despite    treatment) or glaucoma filtration surgery in the study eye-   16. Have pathologic myopia in the study eye-   17. Have a spherical equivalent of the refractive error in the study    eye of >10 diopters of myopia-   18. Have any prior treatment with tyrosine kinase inhibitors-   19. Have an ocular malignancy including choroidal melanoma in either    eye-   20. Are receiving concurrent treatment with medications known to be    toxic to the retina, lens or optic nerve (e.g., chlorpromazine,    phenothiazines, tamoxifen, etc.)-   21. Have a need for chronic therapy with systemic or topical ocular    corticosteroids (a short course of <7 days, if needed during the    study is permissible) or have known allergy to fluorescein (e.g.,    bronchospasm, rash, etc.), or to any component of the study products-   22. Have symptomatic or unstable coronary artery disease, angina,    congestive heart failure, or an arrhythmia requiring active medical    management within the last 30 days of the injection of the implant-   23. Have uncontrolled hypertension (defined as >160/100 mm Hg,    despite medical treatment)-   24. Have a history of or presence of uncontrolled systemic disease    or a debilitating disease (e.g., uncontrolled diabetes).-   25. Have had a myocardial infarction or other cardiovascular event    (e.g., stroke) within the previous 6 months-   26. Have participated in any study involving an investigational drug    either in the U.S. or outside the U.S. within the past 30 days-   27. Are an employee of the site that is directly involved in the    management, administration, or support of the study, or be an    immediate family member of the same.

Study Data Collection—Study Schematic

The study Time and Event Schedule is presented in Appendix A. Proceduresfor study Assessments can be found in Appendix B-G herein at the end ofthe study protocol (i.e., at the end of Example 6.2).

Study Observations and Procedures—Subject Screening and Informed Consent

Potential eligibility will be determined prior to study enrollment. TheInvestigator and study staff will determine the subject's willingnessand ability to meet the follow-up requirements. If the subject desiresto participate in the study, written informed consent will be obtainedprior to performance of any study-specific examinations. Followingcompletion of all the screening and baseline evaluations a determinationwill be made by the Investigator and study staff as to whether or notthe subject has met all the eligibility criteria. If the subject meetsthe eligibility criteria and agrees to participate the subject will beenrolled.

Once a subject qualifies for the study and has received the OTX-TKI theymust be followed to the end of the study period.

If the injection of the OTX-TKI implant is unsuccessful, record thereason for injection failure on the CRF as an injection failure and notas an AE.

Once the implant is placed in the vitreous the Investigator shouldverify placement by indirect ophthalmoscopy. At the discretion of theInvestigator, images of the implant may be obtained throughout theduration of the study.

If the injection of the OTX-TKI implant is unsuccessful, an additionalsubject will be assigned to the study according to the same cohort.

Study Observations and Procedures—Screen Failures

Subjects who have signed the Informed Consent Form, but are determinedto be ineligible during the screening assessments or at the baselinevisit but prior to assignment to a cohort will be considered screenfailures, will be withdrawn from the study, and will not requireadditional study follow-up visits. The reason(s) for the screen failurewill be recorded in the CRF.

If subjects who fail eligibility criteria experience an AE duringScreening/Baseline, they will be followed until the AE is resolved orstabilized.

Study Observations and Procedures—Subject Withdrawal

All subjects treated in the study will be required to adhere to thefollow-up schedule as described in this protocol.

Subjects may withdraw from the clinical study at any time for any reasonwithout jeopardy or prejudice and without compromising their clinicalcare by the Investigator. The Investigator also has the right towithdraw subjects from the trial in the event of an intercurrentillness, AE, protocol violation and/or administrative reason.

For any subject who withdraws their consent following injection ofOTX-TKI, to the extent possible, the reason(s) for withdrawal will bedocumented on the End of Study CRF.

If the withdrawal from the study is a result of an AE, or death, an AEForm will also be completed. If a subject is withdrawn from the study asa result of an AE, every attempt should be made by the Investigator tofollow the subject until the AE has resolved or stabilized.

Every attempt will be made to contact subjects who are non-compliant orlost to follow-up and such attempts will be documented in the subject'sstudy record.

Subjects who withdraw from the study after receiving the OTX-TKI(axitinib implant) for intravitreal use will not be replaced.

Study Observations and Procedures—Product Malfunctions

Following injection, the Investigator will evaluate (i.e. grade) theease of injection including whether or not there were technical problemssuch as a failure of the injection device to inject the implant. Allmalfunctions of the OTX-TKI (axitinib implant) for intravitreal use willbe documented on the appropriate CRF and reported to Ocular Therapeutixwithin 24 hours. Ocular Therapeutix will advise whether the injectiondevice will be returned for analysis. The incidence of malfunctions willbe included in the final analysis.

Study Observations and Procedures—Cohort Group Assignment

This is an open-label, dose escalation Phase 1 study. The PrincipalInvestigator will make the determination of eligibility for each subjectbased on the Inclusion and Exclusion criteria.

For Cohort 1, the first subject will receive the OTX-TKI implant in thestudy eye before any additional subjects are treated. Once the firstsubject in Cohort 1 has been evaluated for two weeks, and the MMsupports continuation, an additional five subjects will be treated inCohort 1.

Once Cohort 1 has been fully enrolled and all safety and tolerabilitydata of OTX-TKI for each subject (minimum follow up data for two weeks)has been collected, the DSMC and MM will conduct a review of allavailable clinical data.

Subjects in Cohort 2 will be treated only after:

-   -   1. All subjects in Cohort 1 have received the OTX-TKI implant        and have been followed for at least 2 weeks    -   2. Confirmation that no more than 1 out of the 6 subjects has        experienced a DLT    -   3. The DSMC completes a safety review of all available clinical        data and recommends dose escalation.

Once Cohorts 1 and 2 have been fully enrolled and all safety andtolerability data of OTX-TKI for each subject (minimum follow up datafor two weeks) has been collected, the DSMC and MM will conduct a safetyreview of all clinical data and will provide their recommendations fordose escalation and continuation.

Cohort 3 will consist of approximately 12 subjects. Six subjects willreceive 600 μg OTX-TKI (Cohort 3a: Monotherapy Treatment Group), and 6will receive 400 μg OTX-TKI along with a single anti-VEGF injection(Cohort 3b: Combination Treatment Group). Cohort 3a (MonotherapyTreatment Group: 600 μg OTX-TKI) will be enrolled prior to Cohort 3bCombination Treatment Group (400 μg OTX-TKI along with a singleanti-VEGF injection).

Study Observations and Procedures—Masking

This is an open-label unmasked safety study.

Study Observations and Procedures—Rescue Therapy

If needed, any subject in any treatment arm may receive rescue therapy(i.e., anti-VEGF) at the Investigator's discretion. Eligibility toreceive rescue therapy will be at the Investigator's discretion andshould be communicated to the medical monitor within 3 days of treatmentif not sooner. Subjects receiving rescue therapy should return for anunscheduled visit plus SD-OCT imaging 7-10 days following treatment ifno per-protocol study visit is scheduled during that timeframe. Subjectsreceiving rescue therapy will be followed to the last study visit. Thefollowing criteria will be used to identify subjects who will likelyrequire rescue therapy:

-   -   i. loss of 15 letters from best previous BCVA due to ARMD, with        current BCVA not better than baseline; or    -   ii. Loss of 10 letters on 2 consecutive visits from best        previous BCVA due to AMD, with current BCVA score not better        than baseline.    -   iii. Evidence of worsening disease activity manifest by greater        than 75 microns CSFT from previous best value

Study Observations and Procedures—Prohibited Medications

The concomitant use of prohibited drugs with OTX-TKI must be avoidedbeginning 14 days prior to the injection of the implant and continuingfor 9 months after the injection.

Co-administration of OTX-TKI and strong CYP3A4/5 inhibitors must beavoided as the plasma bioavailability of axitinib following intravitrealadministration is not known. It has been shown that axitinib exposure(i.e., C_(max)) increased following co-administration with oralketoconazole. The following are not permitted at any time beginning withthe first screening visit: Ketoconazole, itraconazole, clarithromycin,atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir,telithromycin, voriconazole.

Co-administration of OTX-TKI and strong CYP3A4/5 inducers must beavoided as it has been shown that axitinib exposure (i.e., C_(max))decreased following co-administration with rifamycin. The following arenot permitted: Rifamycin, rifabutin, rifapentine, phenytoin,carbamazepine, phenobaribital, hypercium (St. John's wort). Intermittentuse of topical and oral steroids is permitted.

Study Observations and Procedures—Fundus Imaging, FluoresceinAngiography, Optical Coherence Topography

Photographers must be certified by the Central Reading Center beforeimaging of any study subjects. Imaging will follow a standard protocol.

OCT technicians must also be certified by the Central Reading Center.Spectral domain (SD) OCT images will be made using the Cirrus OCTfollowing a standard protocol.

Instructions for these procedures will be provided in a separate imagingmanual.

Study Observations and Procedures—Assessment of Pharmacokinetic Analysis

Plasma levels of axitinib will also be determined; samples will be takenat Screening, Baseline, Day 3 (Visit 3) and Month 3 (Visit 8). Forsubjects in Cohort 3 who receive three separate OTX-TKI injections (600μg group) that may be spaced out over 1-4 weeks at Investigator'sdiscretion, the Day 3 (Visit 3) sample for pharmacokinetic analysis maybe obtained at the same study visit during which the third and finalimplant is injected. Instructions are provided in the Lab Manual.

Study Observations and Procedures—Medical History and ConcurrentMedications

The entirety of the subject's medication treatment history for AMD is tobe recorded on the subject's source document form and correspondingCRFs. Additionally, any other concurrent ophthalmic medications andsystemic medications, from up to 3 years prior to the Screening Visit,are to be recorded on the subject's source document forms andcorresponding CRFs along with the reason the medication was taken,starting at the Screening Visit through the end of the study.

All ophthalmic and cardiac medical history for the subject should alsobe recorded on the subject's source document form and correspondingCRFs. Additional significant medical history from up to 5 years prior tothe Screening visit should be recorded on the subject's source documentform and corresponding CRFs.

Study Assessments Screening Evaluations: Days −14 to Day 0

At the screening visit, the Principal Investigator will make the initialdetermination of the subject's eligibility for study participation bychecking all inclusion and exclusion criteria. If a subject does notmeet all of the inclusion criteria and/or meets any of the exclusioncriteria the subject will be a screen failure and no further assessmentswill be done. Details of the procedures for these assessments can befound in Appendices B-G to this section.

The following procedures and assessments may be initiated within 14 daysprior to the planned day of injection and must be completed prior toInjection Day (Visit 2/Day 1) in the following recommended order:

-   -   Obtain written informed consent    -   Demographic information to include age, gender, race, ethnicity    -   Medical and ophthalmic history including treatment and        procedures    -   Inclusion and exclusion criteria    -   Prior and concomitant medications    -   Vital signs (pulse rate, blood pressure, and temperature)    -   Electrocardiogram—evidence of an electrocardiogram within 12        weeks prior to injection Day 1 that shows no clinically        significant abnormalities (see Appendix G) must be recorded in        the CRF    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated fundus exam including fundus imaging    -   SD-OCT    -   OCT-A    -   Fluorescein angiography    -   Plasma sample for PK analysis    -   Safety Laboratory testing    -   Adverse event assessment    -   Urine pregnancy test: if female of childbearing potential,        subject must utilize two forms of adequate contraception from        screening through the end of the study following injection of        the implant, and have a negative urine pregnancy test

NOTE: All examinations need to be performed on both eyes.

For screen failures due to reasons that are expected to be temporary onere-screening visit can be conducted. The re-screening visit should bescheduled at least 14 days after the 1^(st) screening visit. Subjectswho are re-screened will be given a new subject number and need to haveall screening procedures repeated (including signing of a new InformedConsent). It should be noted on the CRF that this subject is are-screen.

For eligible subjects, all information must be recorded in the subject'sCRF. For subjects who do not meet the eligibility criteria, the minimuminformation to be recorded in the CRF will be the following: date ofscreening, subject number and reason for screen failure.

Injection Day, Visit 2 (Day 1)

Prior to Injection

Prior to injection of the OTX-TKI implant the Principal Investigator andstudy staff must confirm eligibility of the subject and the study eye.

The following procedures and assessments will be performed prior toinjection of the OTX-TKI:

-   -   Inclusion and exclusion criteria confirmation    -   Adverse events (prior to injection)    -   Concomitant medications    -   Vital signs (pulse rate, blood pressure, and temperature)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated Fundus Exam    -   SD-OCT    -   Ocular comfort score (to be assessed by subjects)        (pre-injection)

NOTE: All examinations need to be performed on both eyes.

Injection Procedure

At the conclusion of all the assessments on Visit 2, Day 1 as notedabove, the Investigator will confirm that the subject continues to beeligible for the study and did not experience any protocol definedexclusion criteria.

Subjects can have only one eye treated with OTX-TKI. If both eyes areeligible the eye with the worse BCVA will be selected as the study eye.If both eyes are eligible and both eyes have the same BCVA then theInvestigator will determine which eye will be selected as the study eye.

The contralateral eye, designated as the non-study eye (NSE), if needed,will be treated at the Investigator's discretion with a local therapy,e.g., either topically or intravitreally administered therapy, notsystemic. This should be standard of care and in no case should anotherinvestigational drug be used for the contralateral eye. Thecontralateral eye must not be treated with OTX-TKI. The treatment of theNSE should remain consistent for the duration of the study.

OTX-TKI is for intravitreal use ONLY and should be administered only bya qualified ophthalmologist experienced in the injection procedure.

The study drug treatment will be administered by the Investigatoraccording to the procedure described and detailed in the Study ReferenceManual. For Cohort 3 subjects receiving 3 separate injections, at thediscretion of the Investigator, administration of the OTX-TKI implantsand anti-VEGF may be spaced out over 1-4 weeks.

Post-Injection Procedure

Subjects should be monitored for visual acuity after the injection ofOTX-TKI. Within 30-60 minutes following injection of OTX-TKI:

-   -   A Plasma sample for PK analysis will be drawn    -   The subject should be monitored for elevated IOP.    -   The subject should be monitored until the IOP is stable and <25        mmHg. The Investigator should be prepared to provide therapy in        the event of persistent elevated IOP.    -   The Investigator should visualize the optic nerve head at this        time to verify perfusion during the immediate post-injection        period.

Prior to discharge from the visit the Investigator and study staff areresponsible to ensure that:

-   -   Vision has stabilized and that the IOP is stable and <25 mmHg    -   Adverse events post-injection have been recorded in the CRF    -   The Investigator has recorded the ease of injection procedure        (i.e., ‘utilization’); the Investigator will grade the level of        ease of injection of the intravitreal implant as “easy” (1),        “moderate” (2) or “difficult” (3)    -   Subjects are instructed to refrain from rubbing their eyes and        to contact the Investigator in the event that they experience        excessive pain, eye redness, photophobia, excessive discomfort,        or loss of vision that lasts more than a few hours.    -   Subjects are instructed that a member of the study staff will        reach them by telephone on the next day following the injection        of OTX-TKI to assess whether they have experienced an Adverse        Event. The subject should also be informed that they may be        asked to return to the clinic sooner that the Day 3 (Visit 3).

Post-Administration Follow up Safety Call (Day 2)

A qualified member of the study staff will telephone each subject on theday following the injection procedure to assess whether the subject hasexperienced an Adverse Event. If there is suspicion of an Adverse Event,the subject may be asked to return to the clinic sooner than the Day 3(Visit 3) study visit.

Follow-Up Visit 3 (Day 3+1 Day)

Visit 3 will take place on Day 3 (+1 Day) after the injection ofOTX-TKI. At this visit the Investigator and study staff will perform thefollowing procedures and assessments:

-   -   Adverse events    -   Concomitant medications    -   Ocular comfort score (to be assessed by subjects)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated Fundus Exam (including documentation of presence or        absence of the OTX-TKI implant)    -   SD-OCT    -   Plasma sample for PK analysis

NOTE: For subjects in Cohort 3 who receive three separate OTX-TKIinjections (600 μg group) that may be spaced out over 1-4 weeks atInvestigator's discretion, the Day 3 (Visit 3) sample forpharmacokinetic analysis may be obtained at the same study visit duringwhich the third and final implant is injected (within 30-60 minutesfollowing injection of the third and final OTX-TKI implant a plasmasample for PK analysis will be drawn).

NOTE: All examinations need to be performed on both eyes.

Follow-Up Visit 4 (Day 7±2 Days)

Visit 4 will take place on Day 7 (+2 days) after the injection ofOTX-TKI. At this visit the Investigator and study staff will perform thefollowing procedures and assessments:

-   -   Adverse events    -   Concomitant medications    -   Ocular comfort score (to be assessed by subjects)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated Fundus Exam (including documentation of presence or        absence of the OTX-TKI implant)    -   SD-OCT

NOTE: All examinations need to be performed on both eyes.

Follow-Up Visit 5 (Day 14±2 Days)

Visit 5 will take place on Day 14±2 days following the injection ofOTX-TKI. At this visit the Investigator and study staff will perform thefollowing procedures and assessments:

-   -   Adverse events    -   Concomitant medications    -   Vital signs (blood pressure only)    -   Ocular comfort score (to be assessed by subjects)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated Fundus Exam (including documentation of presence or        absence of the OTX-TKI implant)    -   SD-OCT

NOTE: All examinations need to be performed on both eyes.

Follow-Up Assessments: Visit 6 (Month 1±2 Days), Visit 7 (Month 2±3Days), Visit 9 (Month 4.5±3 Days) and Visit 11 (Month 7.5±3 Days)

At these visits the Investigator and study staff will perform thefollowing procedures and assessments:

-   -   Adverse events    -   Concomitant medications    -   Ocular comfort score (to be assessed by subjects)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated Fundus Exam (including documentation of presence or        absence of the OTX-TKI implant)    -   SD-OCT

NOTE: All examinations need to be performed on both eyes. Pregnancy testshould be performed on all females of childbearing potential if theyhave missed two consecutive menstrual periods.

Follow-Up Visit 8 (Month 3±3 Days) and Visit 10 (Month 6±3 Days)

Visit 8 will take place 3 months+3 days and Visit 10 will take place 6months+3 days following the injection of OTX-TKI. At this visit theInvestigator and study staff will perform the following procedures andassessments:

-   -   Adverse events    -   Concomitant medications    -   Ocular comfort score (to be assessed by subjects)    -   Vital signs (blood pressure only)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated fundus exam including fundus imaging and documentation        of presence or absence of the OTX-TKI implant    -   SD-OCT    -   OCT-A    -   Plasma sample for PK analysis (At Visit 8 only)    -   Safety Laboratory testing    -   Additionally, at Visit 10 (Month 6) only:    -   Fluorescein angiography    -   Urine pregnancy test: if female of childbearing potential,        subject must utilize two forms of adequate contraception from        screening through the end of the study following injection of        the implant, and have a negative urine pregnancy test

NOTE: All examinations need to be performed on both eyes. At Visit 8(Month 3) a pregnancy test should be performed on all females ofchildbearing potential if they have missed two consecutive menstrualperiods.

Final Follow-Up Visit 12 (Month 9±3 Days)

This is the final follow-up visit, excluding any unscheduled visits thatmay be required to follow an AE that has not resolved or stabilized.This visit will take place 9 months (±3 days) after injection ofOTX-TKI. At this visit the Investigator should confirm that the OTX-TKIimplant is no longer visible on examination. If the implant is stillvisible, the subject should be followed approximately monthly until theimplant is no longer visible. At the Investigator's discretion, subjectswho still have evidence of biological activity at month 9 should befollowed monthly until the CNV leakage has returned to baseline levelsor until the Investigator believes the subject is clinically stable.

All of the following procedures and assessments will be performed:

-   -   Adverse event assessment    -   Concomitant medications    -   Ocular comfort score (to be assessed by subjects)    -   Vital signs (blood pressure only)    -   Electrocardiogram (Appendix G)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated fundus exam including fundus imaging and documentation        of presence or absence of the OTX-TKI implant    -   SD-OCT    -   OCT-A    -   Fluorescein angiography    -   Safety Laboratory testing    -   Urine pregnancy test: if female of childbearing potential,        subject must utilize two forms of adequate contraception from        screening through the end of the study following injection of        the implant, and have a negative urine pregnancy test

NOTE: All examinations need to be performed on both eyes.

Unscheduled Visit

An unscheduled visit may occur at any time that the Investigator decidesit is necessary to see the subject outside of the study visit windows.At the discretion of the Investigator, for Cohort 3 subjects receiving 3separate injections, unscheduled visits may be used to space outadministration of the OTX-TKI implants and anti-VEGF over 1-4 weeks. Asmany of these visits as necessary may be scheduled. Any unscheduledvisits will be recorded on the “unscheduled” visit CRF with the reasonfor the visit.

The examinations and assessments are at the Investigator's discretionbased on the reason for the visit. All examinations and assessments,including those listed below, may be performed at Unscheduled Visits:

-   -   Adverse event assessment    -   Concomitant medications    -   Ocular comfort score (to be assessed by subjects)    -   BCVA (ETDRS)    -   Slit lamp biomicroscopy and external eye exam    -   IOP measurement by applanation (Goldmann) tonometry    -   Dilated Fundus Exam (including documentation of presence or        absence of the OTX-TKI implant)

Adverse Events

Throughout the course of the study, all efforts will be made to remainalert to possible AEs or untoward findings. If an AE occurs, the firstconcern will be the safety and welfare of the subject. Appropriatemedical intervention should be undertaken. Any AEs observed by theInvestigator or study staff or reported by the subject, whether or notascribed to the study treatment, will be recorded on the subject'sAdverse Event CRF.

Documentation regarding the AE should be made as to the nature, date ofonset, end date, severity, relationship to the study drug, action(s)taken, seriousness, and outcome of any sign or symptom observed by thephysician or reported by the subject.

Definition of an Adverse Event

An AE is any untoward medical occurrence in a patient or clinicalinvestigation subject administered a pharmaceutical product and whichdoes not necessarily have a causal relationship with the treatment.

An AE can therefore be any unfavorable and unintended sign (including anabnormal laboratory finding), symptom or disease temporally associatedwith the use of a medicinal (investigational) product, whether or notrelated to the medicinal (investigational) product.

Definition of a Serious Adverse Event (SAE)

An SAE is any untoward medical occurrence that at any dose:

-   -   Results in death    -   Is life-threatening        -   The term “life-threatening” refers to an event in which the            subject was at risk of death at the time of the event; it            does not refer to an event which hypothetically might have            caused death if it were more severe    -   Requires in-patient hospitalization or prolongation of existing        hospitalization    -   Results in persistent or significant disability/incapacity    -   Is a congenital abnormality/birth defect

Medical and scientific judgment should be exercised in deciding whetherother situations should be considered SAEs, such as important medicalevents that might not be immediately life-threatening or result in deathor hospitalization but might jeopardize the subject or might requireintervention to prevent one of the other outcomes listed above.

Examples of such events are intensive treatment in an emergency room orat home for allergic bronchospasm, blood dyscrasias, neoplasms orconvulsion that do not result in hospitalization.

An AE that is assessed as ‘severe’ should not be confused with an SAE.The term “severe” is often used to describe the intensity (i.e.,severity) of a specific event (as in mild, moderate, or severemyocardial infarction); the event itself, however, may be of relativelyminor medical significance (such as a severe headache). This is not thesame as “serious”, which is based on the outcome or action criteriausually associated with events that pose a threat to life orfunctioning. Seriousness (not severity) and causality serve as a guidefor defining regulatory reporting obligations.

Severity

Severity of an AE is defined as a qualitative assessment of the degreeof intensity of the AE as determined by the Investigator or reported tothe Investigator by the subject. The assessment of severity is madeirrespective of relationship to the study drug or seriousness of theevent and should be evaluated according to the following scale:

-   -   Mild Event is noticeable to the subject, but is easily tolerated        and does not interfere with the subject's daily activities    -   Moderate Event is bothersome, possibly requiring additional        therapy, and may interfere with the subject's daily activities    -   Severe Event is intolerable, necessitates additional therapy or        alteration of therapy, and interferes with the subject's daily        activities

For AEs that change in intensity, the start and stop date of eachintensity should be recorded.

Relationship to Intravitreal Implant, Procedure, or Study Drug

For each (S)AE, the Investigator must determine whether the event isrelated to the study drug, the injection procedure or the intravitrealimplant. In order to do so, the Investigator must determine whether, inhis/her medical judgment, there is a reasonable possibility that theevent may have been caused by the study drug, the injection procedure orthe intravitreal implant.

The following is a guideline to be used by the Investigator as a guidewhen assessing the causal relationship of an (S)AE. The attribution ofcausality to the injection procedure, the intravitreal implant or thestudy drug will be identified in the CRF.

-   -   NO RELATIONSHIP SUSPECTED This category applies to those (S)AEs        which, after careful consideration, are clearly and        incontrovertibly due to extraneous causes (disease, environment,        etc.); there is no reasonable probability that the (S)AE may        have been caused by the study drug, the injection procedure, or        the intravitreal implant    -   RELATIONSHIP SUSPECTED The following criteria should be applied        in considering inclusion of an (S)AE in this category:    -   1) It bears a reasonable temporal relationship to the injection        procedure or the presence of the intravitreal implant or the        study drug    -   2) It could not be reasonably explained by the known        characteristics of the subject's clinical state, environmental        or toxic factors or other factors (e.g., disease under study,        concurrent disease(s) and concomitant medications) and modes of        therapy administered to the subject    -   3) It disappears or decreases on removal of the intravitreal        implant    -   4) It follows a known pattern of response to the injection        procedure or the intravitreal implant or the study drug

Where the causal relationship of the AE to the injection procedure orthe intravitreal implant has not been determined, or is unknown, the AEwill be treated as if a relationship is suspected for the purposes ofregulatory reporting.

A suspected AE is any event for which there is a reasonable possibilitythat the study drug caused the AE. “Reasonable possibility” means thereis evidence to suggest a causal relationship between the study drug andthe AE. Types of evidence that would suggest a causal relationshipbetween the study drug and the AE include: a single occurrence of anevent that is uncommon and known to be strongly associated with drugexposure; one or more occurrences of an event that is not commonlyassociated with drug exposure, but is otherwise uncommon in thepopulation exposed to the drug (e.g., tendon rupture); an aggregateanalysis of specific events observed in a clinical trial (such as knownconsequences of the underlying disease or condition under investigationor other events that commonly occur in the study population independentof drug therapy) that indicates those events occur more frequently inthe drug treatment group than in a concurrent or historical controlgroup.

Expectedness

The expectedness of an (S)AE should be determined based upon existingsafety information about the study drug using these guidelines:

-   -   UNEXPECTED: An AE or that is not listed in the study protocol,        IB, or prescribing information for the registered formulation of        axitinib (INLYTA®) or is not listed at the specificity or        severity that has been observed    -   EXPECTED: An AE that is listed in the study protocol, IB, or        prescribing information for axitinib at the specificity and        severity that has been observed

AEs that are mentioned in the IB as occurring with a class of drugs oras anticipated from the pharmacological properties of the drug but arenot specifically mentioned as occurring with the particular drug underinvestigation are to be considered as expected.

The Investigator should initially classify the expectedness of an AE,but the final classification is subject to the Medical Monitor'sdetermination.

Clarifications

Hospitalization

Hospitalization for the elective treatment of a pre-existing condition(i.e., a condition present prior to the subject's signature of theInformed Consent) that did not worsen during the study is not consideredan SAE. Complications that occur during hospitalization are AEs. If acomplication prolongs hospitalization, or meets any of the other SAEcriteria, the complication is an SAE.

Pre-Existing Conditions

Pre-existing conditions (i.e., conditions present or detected at thestart of the study) which worsen during the study, exacerbation of apre-existing illness or an increase in frequency or intensity of apre-existing episodic event or condition are (S)AEs. Anticipatedday-to-day fluctuations of pre-existing condition(s) that do not worsenwith respect to baseline are not (S)AEs.

Worsening or progression of wet AMD is considered to be a “lack ofefficacy” or “failure of expected pharmacological action” per protocoland is already recorded as part of the efficacy assessment and thereforedoes not need to be recorded as an (S)AE. However, the signs andsymptoms and/or clinical sequelae resulting from the lack of efficacymay be reported as an (S)AE if considered by the Investigator to fulfillthe definition of an (S)AE.

Medical or Surgical Procedures

Medical or surgical procedures (e.g., colonoscopy) are not (S)AEs;however, the condition that leads to the procedure may be considered an(S)AE.

In the case of elective medical or surgical procedures, or pre-studyplanned medical or surgical procedures for pre-existing conditions(i.e., a condition present prior to the subject's signature of theInformed Consent) that did not worsen during the study the conditionthat leads to the procedure does not need to be reported as an (S)AE.

Death

Death is not an SAE; the condition that leads to the death is an SAE.

Abnormal Laboratory Values

In the absence of a diagnosis, abnormal laboratory values that arejudged by the Investigator to be clinically significant must be recordedas an (S)AE. Clinical significant abnormal laboratory findings that arepresent at baseline and significantly worsen following the start of thestudy will also be reported as an (S)AE.

Procedures for Reporting Adverse Events

All AEs that are “Suspected” and “Unexpected” are to be reported toOcular Therapeutix and the IRB as required by the IRB/IEC, localregulations and the governing Health Authorities.

All AEs observed during the course of this study from the time thesubject signs the Informed Consent, regardless of severity orrelationship to the study drug or intravitreal implant will be recordedon the appropriate CRF(s). To the extent possible, the event to berecorded and reported is the event diagnosis as opposed to the eventsymptoms.

Any Serious Adverse Event or any severe, sight-threatening AE, whetherascribed to the study treatment or not, will be communicated within 24hours, by telephone, to Ocular Therapeutix or its designee. TheInvestigator must obtain and maintain in his/her files all pertinentmedical records, information, and medical judgments from colleagues whoassisted in the treatment and follow-up of the subject; provide OcularTherapeutix or its designee with a complete case history, which includesa statement as to whether the event was or was not suspected to berelated to the use of the study drug; and inform the IRB/IEC of the AEwithin the IRB/IEC guidelines for reporting SAEs. A written reportdetailing the event, signed by the Investigator, shall be submitted tothe Sponsor or its designee within 5 working days. All subjects whoexperience an SAE must be followed until resolution or stabilization ofthe event and the outcome is reported in the CRF.

Type and Duration of the Follow-up of Adverse Events

AEs will be followed until:

-   -   Resolution of the event, i.e., return to the baseline value or        status or to ‘normal’        -   AEs may be determined to have resolved completely or            resolved with sequelae    -   The Investigator determines, for events that do not end (e.g.        metastasis), the condition to be chronic; the event can be        determined to be resolved or resolved with sequelae    -   The event has stabilized, i.e., no worsening expected by the        Investigator. All AEs will be documented in the CRFs.

For subjects that reach the final scheduled visit (i.e. Visit 12 [Month9]), an unscheduled visit may be conducted thereafter to follow-up onany AEs that the Investigator has not deemed to be resolved orstabilized.

Dose Escalation Criteria and Stopping Criteria

Due to limited human experience with the OTX-TKI implant, the firstsubject in Cohort 1 will receive the OTX-TKI implant in the study eyebefore any additional subjects are treated

Once the first subject Cohort 1 has been evaluated for 2 weeks, and ifthe MM supports continuation, an additional 5 subjects will be treatedin Cohort 1.

Subjects will be treated in Cohort 2 only after:

-   -   1. All subjects in Cohort 1 have received the OTX-TKI implant        and have been followed for at least 2 weeks    -   2. Confirmation that no more than 1 out of the 6 subjects has        experienced a DLT    -   3. The DSMC completes a safety review of all available clinical        data and recommends dose escalation.

If one DLT is identified in Cohorts 1, 2, or 3a, enrollment willcontinue until the cohort has been fully enrolled. If a second DLT isseen in Cohorts 1 or 2, then enrollment will stop. If a second DLT isseen in Cohort 3a, enrollment in that cohort will stop and the previouslower dose will be declared the MTD.

All subjects dosed prior to the decision to stop study enrollment are tocontinue to be followed per the protocol. The decision to stop furtherenrollment in a particular cohort will be made by the MM based onrecommendations from the DSMC.

The specific DLT's which may warrant stopping further enrollment include(but are not limited to):

-   -   Ocular inflammation of 4+ or ocular inflammation of 2-3+ that        does not decrease to ≤1+ within 30 days of onset    -   BCVA decrease of >15 letters on multiple consecutive visits        compared to pre-treatment due to study drug    -   Increase in IOP of >10 mmHg or an IOP of >30 mmHg that does not        return to pre-injection levels within 7 days of treatment

Statistical Methods Statistical and Analytical Plans

This study is not designed to show statistical significance, therefore,there will be no statistical analyses completed. There will be a generalStatistical Plan that will briefly summarize how the data will bepresented, i.e., descriptive statistics, etc.

Determination of Sample Size

For this Phase I study, no formal sample size calculations have beenperformed. The study will enroll up to 6 subjects in the first cohortand the accumulated data will be reviewed by the DSMC before continuingenrollment in the second cohort. After the second cohort of up to 8subjects has been enrolled, the DSMC and MM will review the accumulateddata and provide a recommendation for dose escalation and continuationto Cohort 3, which will enroll up to 12 subjects.

Analysis Datasets

The safety population will consist of all subjects receiving the OTX-TKIimplant. All safety and efficacy analyses will be performed on thesafety population.

Demographics and Baseline Data

Subject disposition will be presented, including the number of subjectsscreened, enrolled and treated. The number of subjects who completed thestudy and reasons for discontinuation will be summarized. Data will bepresented by cohort group and overall.

Demographic and baseline characteristics (including disease and medicalhistory) will be summarized. Data will be presented by cohort group andoverall.

Safety Analyses

Safety will be assessed by ocular and systemic adverse events, ocularcomfort score assessment and other ocular-related outcomes.

Adverse events will be coded using Medical Dictionary for RegulatoryActivities (MedDRA) by system organ class and preferred term. Separatesummaries will be made for adverse events that are related to the studydrug, the injection procedure and the OTX-TKI implant. In addition,serious adverse events will be summarized.

Summaries of other safety related outcomes will be provided. All safetydata will be presented by cohort group and overall.

Efficacy Analyses

Efficacy will be assessed by mean change in CSFT from baseline, meanchange in BCVA from baseline, percent of subjects with clinicallysignificant change in leakage, percent of subjects with a decrease inCSFT of 50 μm, percentage of subjects with SRF, IRF and both SRF and IRFand percent of subjects who needed rescue therapy. Data will bepresented by treatment group and overall.

Pharmacokinetic Data

Systemic OTX-TKI exposure as measured in blood samples will besummarized at each time point. Plasma concentrations and pharmacokineticparameters will be summarized by treatment group and overall. Measuredconcentrations and pharmacokinetic parameters will be presented in datalistings.

Abbreviations

List of abbreviations used for describing the study details:

Abbreviation Meaning AE Adverse Event AMD/ARMD Age-related MacularDegeneration API Active Pharmaceutical Ingredient BCVA Best CorrectVisual Acuity BRB Blood Retinal Barrier CNV Choroidal NeovascularizationCNVM Central Neovascular Membrane COVID-19 Coronavirus Disease 2019 CRCCentral Reading Center CRF Case Report Form CSFT Central SubfieldThickness DLT Dose Limiting Toxicity DME Diabetic Macular Edema DRDiabetic Retinopathy DSMC Data Safety Monitoring Committee ECGElectrocardiography ERG Electroretinography ETDRS Early TreatmentDiabetic Retinopathy Study FA Fluorescein Angiography FDA Food and DrugAdministration GCP Good Clinical Practice IB Investigator's Brochure ICHInternational Conference on Harmonization IEC Independent EthicsCommittee IOP Intraocular Pressure IRB Institutional Review Board IRFIntraretinal Fluid IVT Intravitreal (Intravitreous) MM Medical MonitorMTD Maximum Tolerated Dose NSE Non-study eye NVAMD NeovascularAge-Related Macular Degeneration OCT - (A) Ocular Coherence Tomography(angiography) OHT Ocular Hypertension OTX-TKI Ocular TherapeutixAxitinib Implant for Intravitreal Use PEG Polyethylene glycol PLAPolylactide PVD Posterior Vitreous Detachment RCC Renal Cell CarcinomaRPE Retinal Pigment Epithelium SAE Serious Adverse Event SD-OCT SpectralDomain Optical Coherence Tomography SE Study eye SFNV SubfovealNeovascularization SRF Subretinal Fluid TGA Therapeutic GoodsAssociation TKI Tyrosine Kinase Inhibitor VEGF Vascular EndothelialGrowth Factor

Appendices to the Study Protocol

APPENDIX A TIME AND EVENT SCHEDULE Visit Type Screening/ Follow-upBaseline Visit Injection Telephone Follow-up Follow-up Follow-upFollow-up Follow-up Follow-up Day −14 to Day^(b) Call Day 3 + Day 7 ±Day 14 ± Month 1 ± Month 2 ± Month 3 ± Day 0 Day 1 Day 2 1 day 2 days 2days 2 days 3 days 3 days Visit Number Visit 1 Visit 2 N/A Visit 3 Visit4 Visit 5 Visit 6 Visit 7 Visit 8 Informed Consent X Demographic XInformation Medical and X Ophthalmic History including treatment andprocedures Inclusion and X X Exclusion Criteria Prior and X X X X X X XX Concomitant Medication Adverse events X X X X X X X X Ocular Comfort X^(e) X X X X X X Score (to be assessed by subjects) Vital signs^(c) XX X X ECG X BCVA (ETDRS) X X X X X X X X Slit lamp X X X X X X X Xbiomicroscopy and external eye exam IOP Measurement X X X X X X X X byGoldmann Dilated Fundus X X X X X X X X Exam (including presence orabsence of OTX- TKI) Fundus Imaging X X SD-OCT X X X X X X X X OCT-A X XFluorescein X angiography Injection of OTX- X TKI implantPost-administration X follow-up safety call Urine Pregnancy X test^(f)Plasma sample for X  X^(g)  X^(h) X PK Safety Laboratory X Xanalysis^(d) Visit Type Final Follow-up Follow-up Follow-up Follow-upMonth 4.5 ± Month 6 ± Month 7.5 ± Month 9 ± 3 days 3 days 3 days 3 daysUnscheduled Visit Number Visit 9 Visit 10 Visit 11 Visit 12 Visit^(a)Informed Consent Demographic Information Medical and Ophthalmic Historyincluding treatment and procedures Inclusion and Exclusion CriteriaPrior and X X X X X Concomitant Medication Adverse events X X X X XOcular Comfort X X X X X Score (to be assessed by subjects) Vitalsigns^(c) X X X ECG X X BCVA (ETDRS) X X X X X Manifest Refraction Slitlamp X X X X X biomicroscopy and external eye exam IOP Measurement X X XX X by Goldmann Dilated Fundus X X X X X Exam (including presence orabsence of OTX- TKI) Fundus Imaging X X X SD-OCT X X X X X OCT-A X X XFluorescein X X X angiography Injection of OTX- TKI implantPost-administration follow-up safety call Urine Pregnancy X X X test^(f)Plasma sample for PK Safety Laboratory X X X analysis^(d) ^(a)For anyUnscheduled Visit the Investigator should determine which assessmentsneed to be performed based on the reason for the unscheduled visit; notall assessments need be performed (see section 8.12 for list of requiredassessments). ^(b)Subjects will be monitored 30-60 minutes postinjection (see section 8.5 for details regarding post-injectionmonitoring); for Cohort 3, injections of the OTX-TKI implants andanti-VEGF may be spaced out over 1-4 weeks at the Investigator'sdiscretion. ^(c)Vital signs will encompass assessment of blood pressure,pulse rate and temperature at visits 1 and 2 only. At all other visitsonly the blood pressure measurement will be performed. ^(d)Safetylaboratory assessments comprise: CBC, Chem-7, LFTs and TFT. ^(e)OcularComfort Score to be assessed by subjects' pre-injection of OTX-TKI onVisit 2 (Day 1). ^(f)Pregnancy test will be performed on all females ofchildbearing potential at the Screening/Baseline Visit (Days −14 to 0),Visit 10, Visit 12 and at any time that the subject has missed 2consecutive menstrual periods. ^(g)Plasma sample for PK to be performed30-60 minutes post-injection of OTX-TKI on Visit 2 (Day 1). ^(h)Forsubjects in Cohort 3 who receive three separate OTX-TKI injections (600μg group) that may be spaced out over 1-4 weeks at Investigator'sdiscretion, the Day 3 (Visit 3) sample for pharmacokinetic analysis maybe obtained at the same study visit during which the third and finalimplant is injected (within 30-60 minutes following injection of thethird and final OTX-TKI implant a plasma sample for PK analysis will bedrawn).

Appendix B: Ocular Comfort Score (to be Assessed by Subjects)

Subjects will be asked to grade their comfort level by asking them thefollowing question: “On a scale of 0 to 10, 0 being very comfortable and10 being very uncomfortable, how comfortable does your eye feel at thistime?”

The examiner will record the number selected by the subject in wholenumbers on the appropriate CRF.

Appendix C: Recommended Procedures for Best Corrected Visual Acuity(BCVA)

Visual Acuity should be evaluated at the beginning of each study visitprior to performing other tests such as Goldmann tonometry andgonioscopy and prior to pupil dilation. Every effort should be made tohave the same BCVA assessor throughout the study period. Visual acuitytesting should be done starting with most recent correction.

BCVA should be measured using a backlit ETDRS chart such as PrecisionVision's or equivalent. It is recommended that the site use a backlit,wall-mounted or caster stand ETDRS distance eye chart with a luminanceof 85 cd/m² set at 4 meters from the subject. A trial lens frame, orphoropter, set at 12.0 mm vertex distance should be used to obtainmanifest refraction measurements. If possible, final refinement ofsphere should be done at 4 meters with a trial lens set.

Eye Charts

All distance visual acuity measurement should be made using anIlluminator Box (or equivalent) set at 4 meters from the subject. Anysubject unable to read at least 20 or more letters on the ETDRS chart at4 meters should be tested at 1 meter according to the instructionsprovided for 1 meter testing. The fluorescent tubes in the light boxshould be checked periodically for proper functioning.

A maximum effort should be made to identify each letter on the chart.When the subject says he or she cannot read a letter, he or she shouldbe encouraged to guess. If the subject identifies a letter as one of twoletters, he or she should be asked to choose one letter and, ifnecessary, to guess. When it becomes evident that no further meaningfulreadings can be made, despite encouragement to read or guess, theexaminer should stop the test for that eye. However, all letters on thelast line should be attempted as letter difficulties vary and the lastmay be the only one read correctly. The number of letters missed or readincorrectly should be noted.

Log MAR Visual Acuity Calculations

The last line in which a letter is read correctly will be taken as thebase log MAR reading. To this value will be added the number “N×0.02”where ‘N’ represents the total number of letters missed up to andincluded in the last line read. This total sum represents the log MARvisual acuity for that eye.

For Example: Subject correctly reads 4 of 5 letters on the 0.2 line, and2 of 5 letters on the 0.1 line.

Base logMAR =0.1 N (total number of letters incorrect =4 on line 0.2 aswell as 0.1) N × T (T = 0.02) =0.08 Base logMAR + (N × T) =0.1 + 0.08logMAR VA =0.18

BCVA examination should begin with the right eye (OD). The procedureshould be repeated for the left eye (OS).

1-Meter Testing

The subject must sit for the 1-meter test. The avoidance of any headmovement forward or backward is particularly important during this test.

Appendix D: Slit Lamp Biomicroscopy Examination

The slit beam observations should be assessed in a dark room using thehighest lamp voltage, an aperture of 0.3 mm, an illumination angle of 30degrees and a magnification of 16×.

The clinician will use a slit lamp to assess the following as normal,abnormal clinically significant or abnormal not clinically significant:

-   -   External adnexa—Presence or absence of lid erythema, edema or        other abnormalities, evaluation of lashes for scurf or other        abnormalities    -   Conjunctiva—presence or absence of edema, erythema or other        abnormalities    -   Iris—presence or absence of stromal or other abnormalities    -   Cornea—clarity, presence or absence of superficial punctate        keratopathy or other abnormalities assess with fluorescein stain    -   Anterior Chamber—adequacy of formation depth, cell score and        flare count    -   Lens—presence or absence of cataract, and severity of opacity,        presence or absence of pseudophakia

Explanation/comments should be provided on the CRF for any abnormalobservations. If a corneal edema is observed, a notation on whether itis general or local should be added.

Anterior Chamber Cells and Flare

Assessment of anterior chamber cells should be performed as follows:

-   -   Low ambient lighting    -   1×1 mm slit beam    -   Highest slit lamp voltage    -   Illumination angle of 45 degrees    -   High magnification

The anterior chamber will be examined for the presence of signs ofocular inflammation. Anterior chamber cell count and flare will begraded using the SUN* Working Group grading scheme: Although an anteriorchamber cell grade of “0” is reported as “<1 cell” in the SUN WorkingGroup grading scheme, it will be characterized as 0 cells in the fieldfor this study.

The anterior chamber cell count will be assessed as the actual number ofcells counted within the slit beam of 1.0 mm height and 1.0 mm widthdescribed above, if fewer than 16 cells are seen. Only white blood cellswill be counted. (Red blood cells and pigment cells are not to becounted). The number of cells counted and the corresponding grade perthe below scale will both be recorded in the CRF.

Anterior Chamber Cells Grade Number of Cells in Field 0  0 (rare cells,i.e.. one cell in a minority of fields)   0.5+ 1-5 (trace) 1+ 6-15(cells) 2+ 16-25 (cells) 3+ 26-50 (cells) 4+ >50 (cells) Flare GradeDescription 0  None 1+ Faint 2+ Moderate iris and lens details clear 3+Marked iris and lens details hazy 4+ Intense fibrin or plastic aqueous*Standardization of the Uveitis Nomenclature (SUN)¹ If hypopyon ispresent, this should be noted in the source documents and eCRF. ¹Jabs DA, Nussenblatt R B, Rosenbaum J T. Standardization of UveitisNomenclature (SUN) Working Group. Standardization of uveitisnomenclature for reporting clinical data. Results of the FirstInternational Workshop. Am J Ophthalmol. 2005 September; 140(3): 509-16.

Appendix E: IOP Measurement

Goldmann tonometry as the international gold standard for tonometry isquite accurate and reproducible if proper technique is used. Whenperforming Goldmann tonometry the following procedures should befollowed:

-   -   1. Pre-tonometry procedures: Set tonometer in the correct        position and make sure the prism is in the horizontal position        on the slit lamp. Set the tension at 1 mmHg. Use Cobalt filter        with slit beam open maximally with the angle between the        illumination and the microscope at approximately 60 degrees.    -   2. Instill one drop of a topical anesthetic and a moistened        fluorescein strip may be lightly touched against the tarsal        conjunctiva of the lower lid of each eye, taking care not to        flood the ocular surface with fluorescein dye. Alternatively, a        drop of topical anesthetic-fluorescein (e.g., Fluress) solution        may be instilled into the lower conjunctival fornix of each eye,        taking care not to flood the ocular surface with fluorescein        dye. Ask subject to blink a few times just prior to tonometry.    -   3. Place subject in adjustable chair so chin can fit comfortably        on the slit lamp chin rest and the forehead can be snug against        the forehead bar.    -   4. Apply tonometer to the subject's eye while subject looks        straight ahead and increase the force of applanation until the        observer sees the inner portion of the two half fluorescein        circles are touching. Record pressure on the CRF.

Appendix F: Dilated Fundus Exam

Assessments should be conducted using indirect ophthalmoscopy. Each ofthe following will be evaluated and documented as normal, abnormalclinically significant or abnormal not clinically significant:

-   -   Vitreous: When examining the vitreous, the Investigator should        also document the presence or absence of the OTX-TKI implant at        the macula, peripheral retina, choroid, and optic nerve.

The cup to disc (C/D) ratio will also be measured. Explanation/commentshould be provided on the CRF for any abnormal pathology.

The following scale will be used to define the extent of vitreous haze²:Absent Clear view of optic disc, retinal vessels and nerve fiber layerTrace Slight blurring of optic disc margin and of normal striations andreflex of nerve fiber layer cannot be visualize 1+ Mild blurring ofoptic disc margin and slight loss of retinal vessel definition 2+Moderate blurring of optic disc margin and loss of retinal vesseldefinition 3+ Optic nerve head and large vessels visible but bordersquite (very) blurry 4+ Optic nerve head obscured ²Nussenblatt R B,Palestine A G, Chan C C, Roberge F. Standardization of vitrealinflammatory activity in intermediate and posterior uveitis.Ophthalmology 92: 467-471, 1985.

Appendix G: Electrocardiogram (ECG) 12-Lead ECG

A 12-lead ECG will be performed during the Screening Phase. An ECG willbe performed after the subject has been supine for approximately 3minutes. Sites are to use their own, local ECG machines for the studyand the ECG readings will be interpreted by the Investigator (ordelegated qualified designee) by clinically correlating with thesubject's condition.

The Investigator's interpretation will be recorded in the ECG eCRF as:normal; abnormal, not clinically significant; or abnormal, clinicallysignificant. Results must be within normal limits or not clinicallysignificant in order to allow a subject to continue in the study.

Example 6.3: Initial Results of the Study

Initial studies were performed in human subjects as follows: Subjectswith neovascular age-related macular degeneration (nAMD, bothtreatment-naïve and those with a history of anti-VEGF therapy) wereenrolled for administration of inventive hydrogel in a single study eye.Two groups completed enrollment and are under evaluation: 200 μgaxitinib in a 7.5% PEG hydrogel (formed from 2 parts 4a20K PEG-SAZ to 1parts 8a20K PEG amine) where the 7.5% represents the PEG weight dividedby the fluid weight×100 (1 implant; n=6) and 400 μg axitinib (2implants; n=7). Spectral-domain optical coherence tomography (SD-OCT)imaging was used to assess retinal fluid and central subfield thickness(CSFT) was performed at Baseline. Injection visits occurred at days 3,7, and 14, and at months 1, 2, 3, 4.5, 6, 7.5, 9, and approximatelymonthly until implant(s) were no longer visible. The inventive implantswere visualized at every visit. Safety evaluations included: adverseevent collection, vital signs, best-corrected visual acuity (BCVA), slitlamp biomicroscopy, tonometry, indirect and direct ophthalmoscopy andsafety labs.

In the 400 μg group, an average reduction in central subfield thickness(CSFT) of 89.8±22.5 μm (mean±SEM) was observed by 2 months and wasgenerally maintained through the 3 month timepoint (follow-up ongoing).For several subjects with a history of anti-VEGF therapy, the durabilityof anti-VEGF treatment was extended to >9 months in the 200 μg groupand >3 months in the 400 μg group (follow-up ongoing). Best-correctedvisual acuity (BCVA) was maintained with no serious ocular adverseevents reported. The most common adverse events observed in the studyeye include tiny pigmented keratic precipitates (3/13), subretinalhemorrhage (2/13) and subconjunctival hemorrhage (3/13) and pain (2/13)following implant injection. Implant(s) exhibited little movement in thevitreous and were no longer visible after 9-10.5 months in the 200 μggroup.

The inventive implants were generally well-tolerated with a favorablesafety profile. Minimal movement and consistent resorption of implant(s)has been observed up to 10.5 months.

Detailed results of the continuation of these initial studies with 200μg (1 implant) and 400 μg (2 implants) axitinib doses and additionalstudies with a 600 μg (3 implants) axitinib dose as well as a 400 μg (2implants) axitinib dose concurrently administered with an anti-VEGFagent are reported in detail in Example 6.4.

Example 6.4: Comprehensive Results of the Study Evaluation of Doses of200 and 400 μg Axitinib

As explained in the study protocol reproduced above, participants ofcohort 1 (n=6) received one implant comprising an axitinib dose of 200μg in one eye per patient and participants of cohort 2 (n=7) receivedtwo implants each comprising an axitinib dose of 200 μg in one eye perpatient resulting in 400 μg dose in total per eye. Implants wereadministered intravitreally using a 27G needle. Even in the hydratedstate the implants did not result in visual impact due to their compactsize and shape. Patients of cohort 2 received the two implants on thesame day, with the exception of subject #2 who received the implants 1week apart. For formulation details and dimensions of the 200 μg implantused in this study see Table 21.1 (Implant #1). Overview chartspresenting summary data regarding central subfield thickness (CSFT) andbest corrected visual acuity (BCVA) of all subjects enrolled andanalyzed so far in cohorts 1 and 2 are provided in FIGS. 17 and 18,respectively. In addition, in order to exemplary illustrate the courseof CSFT and BCVA in subjects of cohorts 1 and 2, certain specificsubjects are discussed herein in more detail, and images showing theCSFT and BCVA in these subjects at exemplary visits are provided in theFigures. These exemplary subjects are discussed to illustrate CSFT andBCVA measurement and development in subjects/patients who participatedin the study, but are singular subjects. For the mean change of CSFT andBCVA over all subject of cohorts 1 and 2, it is referred to FIGS. 17 and18. For FIGS. 17 and 18, six patients were followed in cohort 1 untilmonth 9. Seven patients were followed in cohort 2 until month 12, fiveuntil month 14 and two until month 16.

31% (4 of 13) patients in cohorts 1 and 2 were female, 69% (9 of 13)were male with a median age of 75.2 years (standard deviation, SD: 4.5),wherein the youngest patient was 67 and the oldest patient 83 years.Participants of both cohorts were either previously treated withanti-VEGF therapeutic (such as ranibizumab or aflibercept) or naïve. Anoverview of the subjects from cohort 1 and 2 is further given in Table22. The baseline CSFT for the 6 treated subjects in cohort 1 is 680±159μm (mean±SE), and the baseline BCVA (Snellen equivalent) is 0.73±0.26(mean±SE). The baseline CSFT for the 7 treated subjects in cohort 2 is450±29 μm (mean±SE), and the baseline BCVA (Snellen equivalent) is0.47±0.17 (mean±SE).

TABLE 22 Overview of subjects from the two cohorts (cohort 1 and 2).Age, Sex (male M, female F), together with prior treatment and study eyeare presented. For the study eye (oculus dexter, (OD) or oculus sinister(OS)), pre-treatment BCVA is given as logMAR (logarithm of the minimalangle resolution) and Snellen equivalent. A conversion chart from EDTSletter score to LogMAR value and Snellen equivalent can be found in Becket al., Am J Ophthalmol 2003, 135: 194-205. In addition, CSFTpre-treatment is presented. All pre- treatment results are from day 1 ofthe study, except for cohort 1, subjects 3, 4, and 5 for which data wastaken from the screening visit. Study Eye Pre- Pre- Pre- TreatmentTreatment Treatment Subject Prior Study logMAR Snellen CSFT No. Age SexTreatment Eye BCVA BCVA (μm) Cohort 1 (200 μg) #1 74 M Naïve OS 1.14 @ 1m  20/276 1252 #2 71 M Anti-VEGF OD 0   20/20 350 #3 79 M Anti-VEGF OD0.30 20/40 309 #4 73 F Anti-VEGF OS 1.52 @ 1 m  20/662 742 #5 80 MAnti-VEGF OS 0.36 20/46 408 #6 78 M Naïve OD 1.04 @ 1 m  20/219 1030Cohort 2 (400 μg) #1 72 M Anti-VEGF OD −0.04  20/18 473 #2 75 F Naïve OS1.40 @ 1 m  20/502 513 #3 67 M Anti-VEGF OS 0.36 20/46 561 #4 80 MAnti-VEGF OS 0.28 20/38 448 #5 71 M Naïve OD 0.42 20/53 430 #6 83 FAnti-VEGF OS 0.30 20/40 388 #7 75 F Anti-VEGF OD 0.54 20/69 335

Participants were evaluated for changes in central subfield thickness(CSFT) and retinal fluid by spectral domain optical coherence tomography(SD-OCT), for best corrected visual acuity (BCVA), and forclinically-significant leakage using fluorescein angiography (FA) and/orOCT prior to treatment (baseline values—day 1), on days 3, 7, and 14,and months 1, 2, 3, 4.5, 6, 7.5, 9, 10.5, 11, 12, 13.5, 14, and/or 15.5and approximately monthly for the subjects still in the study until theimplants were no longer visible. In addition, slit lamp biomicroscopy,tonometry (for measurement of IOP), and indirect and directophthalmoscopy were performed on the study visits. Patients weremonitored for adverse events on all study visits.

Biodegradation

Implants exhibited little movement in the vitreous. Generally, implantswere no longer visible after 9-12 months in both cohorts. FIG. 15exemplarily shows IR images for subject #1 of cohort 2.

Visual Quality and Central Subfield Thickness

In general, no substantial increase in the mean CSFT was observed forthe subjects of cohort 1 over the 9-month study duration (FIG. 17). Insome subjects of cohort 1, a reduction of CSFT was observed with the 200μg dose. Subject #1 from cohort 1 (naïve) showed a significant reductionin CSFT in the study eye from 1252 μm (baseline value at day 1) to 936μm (after 10.5 months), while visual acuity (referring to the clarity ofvision) was not impaired in the study eye (FIG. 16). No rescue therapywas needed throughout the study duration of subject #1 (10.5 months).Mean visual acuity (BCVA) was not significantly impaired in the patientsof cohort 1 (FIG. 18), meaning that BCVA was still within 15 ETDRSletters from baseline (determined prior to administration of theimplant).

The mean central subfield thickness (CSFT) was reduced for the subjectsfrom cohort 2 over 14 months (FIG. 17). Moreover, mean visual acuity(BCVA) was not significantly impaired in the patients of cohort 2 (FIG.18).

FIGS. 19A and B, and FIG. 20 exemplarily show images from SD-OCTevaluation of two subjects from cohort 2. Subject #1 from cohort 2 hadbeen treated with aflibercept for over a year (16 months) prior toinjection of the axitinib implants in the right eye (oculus dexter, OD).Subretinal fluid was clearly visible at baseline (pre-treatment).Importantly, the sub-retinal fluid was gone after 2-3 months afterimplant injection and this stage was essentially maintained over thecomplete study duration of 15.5 months without rescue therapy (FIGS. 19Aand B). Up to month 12.5 two implants were visible, thereafter oneimplant was visible. Subject #7 from cohort 2 had been treated withaflibercept for 6 years prior to implant administration. CSFT wasefficiently reduced from 335 μm baseline through month 9 (e.g. CSFT of271 μm at month 9) without rescue therapy (FIG. 20). At month 10 theCSFT started to increase again. Two implants were present until month12. Follow-up is ongoing.

In summary, the clinical data demonstrate efficacy and implantpersistence in the eye for up to about or even beyond 14 months incertain subjects. These observations have not been expected. In the invitro real-time release experiments the complete axitinib dose wasreleased after around 8 months (cf. FIG. 14A).

Plasma Concentration

Plasma concentrations of axitinib were below the lower limit ofquantification (LLOQ<0.1 ng/mL) at all samples time-points in allsubjects, indicating that administration of the implant(s) did not leadto systemic drug exposure. This further validates the overall safety ofthe axitinib implants of the present application.

Tolerability and Adverse Events

In general, the treatment has been safe and well-tolerated. Injectioncourses were uncomplicated for most of the subjects. FA and OCT revealedno clinically significant leakage for any of the subjects throughout thestudy duration. IOPs were normal independent of the dose for allsubjects over the study duration. Inflammation was not observed for anyof the subjects. No subjects needed ocular steroids.

All reported adverse events were mild to moderate, no severe adverseevents or severe ocular adverse events were reported (Table 23).

TABLE 23 Adverse events reported for the cohorts 1 and 2. Cohort 1:Cohort 2: 200 μg 400 μg axitinib axitinib Total Number of subjects with:(n = 6) (n = 7) n = 13 Adverse Events (AEs) 14 22 36 Suspectedrelationship to 1 2 3 study product Suspected relationship to 1 3 4injection procedure Ocular AEs 12 15 27 Ocular AEs in Study Eye 7 13 20Serious Ocular AEs 0 0 0 By severity Mild 12 17 29 Moderate 2 5 7 Severe0 0 0

Adverse events observed in the study eye included tiny pigmented keraticprecipitates (3/13), subconjunctival hemorrhage following injection(3/13) and pain following injection (2/13). Importantly, only 3 adverseevents with suspected relationship to the study product were reported.For example, one patient had opacities around the implant, one patienthad vitreous floaters, three patients had tiny pigmented keraticprecipitates (no treatment required), and one had foreign material(fiber and reflective particles). Further specific adverse events arelisted in the following Table 2).

TABLE 24 Specific adverse events reported for the study eye for thecohorts 1 and 2. Cohort 1: Cohort 2: 200 μg 400 μg axitinib axitinibTotal Number of subjects with: (n = 6) (n = 7) n = 13 Tiny Pigmented KPs3 0 3 Opacities around OTX Implant 1 0 1 Discomfort/Difficulty opening 10 1 eyes on waking Dry eyes 1 0 1 Increased Geographic Atrophy 0 1 1Pain 0 2 2 Vitreous Floaters 0 1 1 Corneal Scratch 0 1 1 Blepharitis 0 11 Subconjunctival Haemmorhage 1 2 3 TKI implant obstruction vision 0 1 1Foreign material noted in vitreous 0 1 1 Worsen cataracts 0 1 1Subconjunctival haemoatoma 0 0 0 Trace anterior chamber cells 0 0 0 Redeye 0 1 1 Watery eye 0 1 1 Eye discomfort 0 0 0 Foreign body sensation 00 0 Small hair in vision 0 0 0

In summary, the axitinib implants of the present invention were safe andwell-tolerated. The implants showed efficient reduction or showedessentially maintenance of CSFT versus the baseline determined prior toadministration of the implant.

Evaluation of 600 μg Axitinib Dose and 400 μg Axitinib Dose withAnti-VEGF Co-Administration

To further explore efficacy of the implants in humans, further clinicalstudies are ongoing with one cohort (cohort 3a) of subjects sufferingfrom wet AMD (planned: n=6) receiving three of the 200 μg implants(Table 21.1, Implant #1) as separate injections resulting in a totalaxitinib dose of 600 μg per eye, as well as with another cohort (cohort3b) of subjects suffering from wet AMD (planned: n=6) receiving two ofthe 200 μg implants (Table 21.1, Implant #1) as separate injectionsresulting in a total axitinib dose of 400 μg per eye and in additionreceiving a single anti-VEGF injection (Avastin or EYLEA®), which isadministered during the same session as the placement of the implants.One eye per patient is treated.

For cohort 3a, all 6 subjects have started treatment and are currentlybeing treated, for cohort 3b, 2 subjects from the planned number of 6subjects have started treatment and are currently being treated. Two outof the 8 currently treated subjects are female, 6 are male. The baselineCSFT for the 8 currently treated subjects in cohort 3 is 518±53 μm(mean±SE), and the baseline BCVA (Snellen equivalent) is 0.88±0.12(mean±SE). In general, implants exhibited limited movement in thevitreous. An overview of the subjects enrolled to date in cohorts 3a and3b is provided in Table 25. Overview charts presenting summary dataregarding central subfield thickness (CSFT) and best corrected visualacuity (BCVA) of all subjects enrolled and analyzed so far in cohorts 3aand 3b are provided in FIGS. 17 and 18, respectively. In addition, inorder to exemplary illustrate the course of CSFT and BCVA in subjects ofcohorts 3a and 3b, certain specific subjects are discussed herein inmore detail, and images showing the CSFT and BCVA in these subjects atexemplary visits are provided in the Figures. These exemplary subjectsare discussed to illustrate CSFT and BCVA measurement and development insubjects/patients who participated in the study, but are singularsubjects. For the mean change of CSFT and BCVA over all subject ofcohorts 3a and 3b, it is referred to FIGS. 17 and 18. For the charts inthese FIGS. 17 and 18: Six patients were followed in cohort 3a until day14, five until month 2, two until month 4.5, and one until months 6 and7.5. Two patients were followed in cohort 3b until month 3, and oneuntil month 4.5. Follow-up is ongoing.

TABLE 25 Overview of subjects from the two cohorts (cohort 3a and 3b).Age, Sex (male M, female F), together with prior treatment and study eyeare presented. For the study eye (oculus dexter, (OD) or oculus sinister(OS)), pre-treatment BCVA is given as logMAR (logarithm of the minimalangle resolution) and Snellen equivalent. A conversion chart from EDTSletter score to LogMAR value and Snellen equivalent can be found in Becket al., Am J Ophthalmol 2003, 135: 194-205. In addition, CSFTpre-treatment is presented. All pre-treatment results are from day 1 ofthe study. Study Eye Pre- Pre- Pre- Treatment Treatment TreatmentSubject Prior Study logMAR Snellen CSFT No. Age Sex Treatment Eye BCVABCVA (μm) Cohort 3a (600 μg) #1 79 M Naïve OS 0.58 20/76  484 #2 84 MNaïve OD 0.70 20/100 551 #3 72 M Naïve OD 0.32 20/42  481 #4 70 MAnti-VEGF OS 1.04 20/219 825 #5 78 F Naïve OS  1.1 @ 1 m 20/252 320 #684 M Naïve OD 1.1  20/252 466 Cohort 3b (400 μg + anti-VEGF) #1 71 MNaïve OD 0.88 @ 1 m 20/152 423 #2 80 F Anti-VEGF OS 1.34 @ 1 m 20/438559

Visual Quality and Central Subfield Thickness

The first patient of cohort 3a (3×200 μg implant) is a 79 year-old male,who is naïve for AMD treatment. The injection course was uncomplicated.The implants were placed over one week (on days 1 (baseline) and 7) inthe left eye (OS). Notably, CSFT was efficiently reduced over the first7.5 months while BCVA remained unaffected (FIG. 21). The second patientof cohort 3a (3×200 μg implant; not shown in the Figures) is an 84year-old male, who is naïve for treatment. The injection course wasuncomplicated. The three implants were placed all in one day (day 1,baseline). CSFT was essentially stabilized for 4.5 months, i.e., did notclinically significantly increase. Follow-up is ongoing.

Generally, mean CSFT was greatly reduced at 6 months after insertion ofthe implants in patients of cohort 3a (FIG. 17). Mean BCVA increasedmarkedly for cohort 3a after 3 months (FIG. 18).

The first patient of cohort 3b (2×200 μg implant and anti-VEGF) is a 71year old male, who is naïve for AMD treatment. The injection course wasuncomplicated. The implants and the anti-VEGF injection were all placedon day 1 (baseline) in the right eye (OD). Already after 7 days a clearreduction in CSFT was visible while BCVA was not affected. The CSFT wasfurther reduced and then essentially maintained over a 3 month treatmentperiod, and started to increase at month 4.5 (FIG. 22). The secondpatient of cohort 3b had received anti-VEGF therapy for 7 months priorto insertion of the implants. Even after a short treatment period ofonly 7 days the CSFT was reduced by ⅔ (599 μm at baseline and 188 μm atday 7), while BCVA was not affected (FIG. 23). A low CSFT value wasmaintained through month 2, but started to increase at month 3. Thesubject received rescue therapy at month 4.5. Follow-up is ongoing.

Mean CSFT was efficiently reduced during the first 3 months afterinsertion of the implants in patients of cohort 3b (FIG. 17). Mean BCVAslightly increased (FIG. 18).

Tolerability and Adverse Events

In general, also the implants in cohort 3a and 3b have been safe andwell-tolerated. Injection courses were uncomplicated for most of thesubjects. IOPs were normal independent of the dose for all subjects overthe study duration. Inflammation was not observed for any of thesubjects. No subjects needed ocular steroids.

All reported adverse events were mild, no moderate or severe (ocular)adverse events were reported (Table 26.1). Importantly, only one adverseevent with suspected relationship to study product was reported so far(see Table 26.1). Specific adverse events are reported in Table 26.2.Follow-up is ongoing for cohorts 3a and 3b.

TABLE 26.1 Adverse events reported for cohorts 3a and 3b (follow-upongoing). Cohort 3b: Cohort 3a: 400 μg 600 μg axitinib + axitinibAnti-VEGF Total Number of subjects with: (n = 6) (n = 2) n = 8 AdverseEvents (AEs) 14 3 17 Suspected relationship to 1 0 1 study productSusptected relationship to 9 2 11 injection procedure Ocular AEs 12 2 14Ocular AEs in Study Eye 10 2 12 Serious Ocular AEs 0 0 0 By severityMild 14 3 17 Moderate 0 0 0 Severe 0 0 0

TABLE 26.2 Specific adverse events reported for the study eye forcohorts 3a and 3b so far (follow-up ongoing). Cohort 3b: Cohort 3a: 400μg 600 μg axitinib + axitinib anti-VEGF Total Number of subjects with:(n = 6) (n = 2) n = 8 Tiny Pigmented KPs 0 0 0 Opacities around OTXImplant 0 0 0 Discomfort/Difficulty opening 0 0 0 eyes on waking Dryeyes 0 0 0 Increased Geographic Atrophy 0 0 0 Pain 2 1 3 VitreousFloaters 0 0 0 Corneal Scratch 0 0 0 Blepharitis 0 0 0 SubconjunctivalHaemmorhage 3 1 4 OTX Implant obstruction vision 0 0 0 Foreign materialnote in vitreous 0 0 0 Worsen Cataracts 0 0 0 SubjconjunctivalHaemoatoma 1 0 1 Trace anterior chamber cells 1 0 1 Red eye 0 0 0 Wateryeye 0 0 0 Eye discomfort 1 0 1 Foreign body sensation 1 0 1 Small hairin vision 1 0 1

Alternatively, instead of three implants providing a total dose of 600μg, one implant comprising a dose of 600 μg axitinib may be injected. Ofnote, injection of a 600 μg bolus dose in rabbits (cf. Example 3.6) didnot result in significant tissue changes and inflammatory responses werenormal. Formulation and dimension of 600 μg implants suitable for use inclinical studies are presented in Table 21.2.

Rescue Medication

If needed, according to the study protocol reproduced above any subjectin any of cohorts 1, 2, 3a and 3b has received rescue therapy (ananti-VEGF agent, specifically an intravitreal injection of 2 mgaflibercept) at the investigator's discretion. The following criteriawere used to identify subjects who would likely require rescue therapy:

-   -   loss of ≥15 letters from best previous BCVA due to AMD, with        current BCVA not better than baseline; or    -   loss of ≥10 letters on 2 consecutive visits from best previous        BCVA due to AMD, with current BCVA score not better than        baseline; or    -   evidence of worsening disease activity manifest by greater than        75 microns CSFT from previous best value.

Not more than 50% of the subjects from cohorts 1, 2, 3a, and 3b requiredrescue medication as defined herein in the form of an anti-VEGFtreatment within the first 6 months after start of treatment (implantinjection) so far (Table 27). For instance, in cohort 2 71.4% of thesubjects did not receive rescue medication at 3 months after implantinsertion, and 6 months after implant insertion 57.1% of subjects didnot receive rescue medication. Even after a long treatment period of 11or 13.5 months in cohort 2, rescue medication was not needed for 28.6%or for 20% of the subjects, respectively (especially in cohorts 3a and3b the studies are still ongoing). This low percentage of subjectsneeding rescue medication demonstrates that the therapeutic effect of areduction of fluid achieved by the implants of the invention ismaintained, and the patients are stabilized at the reduced fluid statefor an extended period of time, such as for at least 3 months, at least6 months, at least 9 months or at least 12 months. Specifically, thedata of cohorts 1 and 2 (200 μg and 400 μg axitinib, respectively) inTable 27 show that the level of fluid in patients that had been achievedby the administration of the implants could be maintained in the periodfrom 6 to 9 months without any need for rescue medication, while vision(expressed by means of the BCVA) was not significantly impaired (seeFIG. 18).

TABLE 27 Percentage of subjects from all cohorts who did not requirerescue therapy. At 3 At 6 At 7.5 At 9 At 11 At 13.5 At 15.5 monthsmonths months months months months months Cohorts % (n/N) % (n/N) %(n/N) % (n/N) % (n/N) % (n/N) % (n/N) Cohort 1 66.7 50 50 50 NA NA NA(200 μg) (4/6) (3/6) (3/6) (3/6) Cohort 2 71.4 57.1 42.9 42.9 28.6 20 20(400 μg)* (5/7) (4/7) (3/7) (3/7) (2/7) (1/5)* (1/5)* Cohort 3a 100 100100 TBD TBD TBD TBD (600 μg)* (3/3)* (1/1)* (1/1)* Cohort 3b 100 TBD TBDTBD TBD TBD TBD (400 μg + (2/2)* anti-VEGF)* *= follow-up is ongoing.TBD = to be determined. Note: in cohort 3a, one subject received rescuemedication at month 1, however this is not yet reflected in Table 27 asof the total of six subjects in cohort 3a only three already reached 3months, and none of these three had received rescue medication (thesubject having received rescue mediaction at month 1 has not yet reachedmonth 3).

The doses of axitinib in implants applied in humans (200-600 μg) aremarkedly lower compared to the approved INLYTA® dose (2×5 mg/day). Evenif an entire 600 μg axitinib dose would be delivered systemically at onetime, this would nevertheless allow a more than 15-fold safety margin ofthis full dose compared to the daily INLYTA® dose, further underliningthe safety of the implants.

The above results demonstrate that the implants of the present inventionadministered to patients diagnosed with neovascular AMD were able tostabilize retinal fluid in these patients (i.e., to either reduce,maintain or at least not significantly increase retinal fluid) asevidenced by the CSFT, while not impairing the patients' vision asevidenced by the BCVA, for a treatment period of about 6 to about 9months or even longer, and that the implants were well tolerated.

Example 6.5: Proposed Human Clinical Trial with a 600 μg AxitinibImplant

The proposed study is a prospective, multi-center, double-masked,randomized, parallel-group study to evaluate the efficacy and safety ofOTX-TKI (600 μg axitinib implant) for intravitreal use in subjects withpreviously treated neovascular age-related macular degeneration (nAMD).The study objective is to evaluate the efficacy and safety of OTX-TKI(0.6 mg axitinib implant) for intravitreal use in previously treatedpatients with neovascular age-related macular degeneration (AMD).

The primary efficacy endpoint will be:

-   -   Mean change in BCVA from baseline to 7 months

The secondary efficacy endpoints will be:

-   -   Mean change in BCVA from baseline over time at all study visits    -   Mean change in central subfield thickness (CSFT) from baseline        over time measured by SD-OCT at 7 months and all study visits        and percent of subjects with no increase in CSFT 50 μm at all        study visits compared to baseline through Month 12    -   Proportion of subjects with absence of retinal fluid (CSFT 300        μm on SD-OCT) at all study visits through Month 12, proportion        of subjects with no clinically significant increase in leakage        from baseline determined by FA at 7 months and all study visits,        proportion of patients with absence of fluid by fluid type        (subretinal fluid (SRF) or Intraretinal fluid (IRF); CSFT 300 μm        on SD-OCT) at all study visits    -   Proportion of subjects receiving rescue therapy, mean time to        rescue therapy, and mean number of rescue therapy injections        through Month 4, 7, and 12.

Safety endpoint will be:

-   -   Incidence of treatment emergent adverse events (AEs)    -   Vital signs changes over time    -   Ocular Comfort Score changes over time    -   Clinically relevant vision loss defined as a 6-line loss in        vision compared to baseline over time    -   Clinically significant change in ocular examination compared to        baseline assessments (e.g., slit lamp biomicroscopy, fundus        exam, and IOP) over time.

Approximately 100 subjects of age 50 will be enrolled and treated with0.6 mg OTX-TKI (intravitreal implant) or 2 mg aflibercept (intravitrealinjection). Following confirmation of eligibility at Visit 1(Screening/Baseline), the subjects will be randomized 1:1 to one of twogroups. Subjects randomized to OTX-TKI will receive a single injectionof 0.6 mg OTX-TKI (0.6 mg axitinib), and subjects randomized toaflibercept will receive a sham (i.e., vehicle only) injection. At Visit2 (Month 1) subjects randomized to OTX-TKI will receive a singleinjection of 2 mg aflibercept and subjects randomized to afliberceptwill receive a single injection of 2 mg aflibercept (i.e., all subjectswill receive an injection of 2 mg aflibercept at Visit 2/Month 1).Subsequently, subjects randomized to the aflibercept group will receivea single injection of 2 mg aflibercept every two months and subjectsrandomized to the OTX-TKI group will receive a sham injection every twomonths. The planned study design is shown in FIG. 28.

The study population will be subjects with a diagnosis of previouslytreated subfoveal neovascularization (SFNV) secondary to neovascular AMDwith leakage involving the fovea who received their most recentanti-VEGF injection within the prior 1-4 weeks.

Example 7: Inflammation Study with Various TKIs

TKI sample preparation: Hydrogels containing several TKIs were preparedfor tolerability testing in rabbit eyes: sunitinib axitinib, nintedaniband regorefanib. First, a diluent solution of 80% Provisc (Alcon, Inc.)and 20% of a 0.5 mg/mL sodium borate solution (pH 6.8) was prepared.Next, mixtures containing 9.6% API, 77.8% diluent, 8.4% 4a20kPEG SAZ and4.2% 8a20kPEG NH₂ were prepared. Prior to gelation, which occurredbetween 3.5 to 8 minutes after mixing, 10 μL was injected intravitreallyin New Zealand white rabbit eyes using a Hamilton syringe.

Study Design: Briefly, on Day 0 rabbits were injected in the left andright eye with test articles as listed below in the study design table.Animals were euthanized at 2 weeks. Eyes were harvested, and fixed inDavidson's solution for histopathologic analysis.

TABLE 28 List of TKIs used in the inflammation study. Treatment Group(OU) Endpoint 1 Sunitinib Histopathology 2 Nintedanib Histopathology 3Regorefanib Histopathology 4 Axitinib Histopathology 5 ShamHistopathology

Tissues examined: A total of 10 left and right eyes from 5 rabbits weresubmitted to Mass Histology and trimmed by a board-certified veterinarypathologist.

Conclusion: Under the conditions of the study intravitreal injection ofrabbit eyes with formulations of hydrogel depots with tyrosine kinaseinhibitors at 14 days post-injection resulted in the continued presenceof the hydrogel in the vitreous chamber of at least one eye from eachgroup except Group 1 and Group 3 where no hydrogel material was noted ineither eye.

Inflammation was never present around any of the injected materialobserved in any of the eyes from Groups 2, 4, and 5. Minimalinflammation composed primarily of macrophages in the vitreous chamberand/or attached to the retina was observed in occasional samples fromGroups 1 and 3. Again, no injected material was observed in either eyefrom Group 1 or Group 3.

Minimal inflammation and fibrosis were observed in a few slide samplesfrom Groups 3 and 4. These were typically small linear areas of fibrosiswith a few macrophages admixed. They are interpreted as sequela toneedle injection.

One or a few small areas of retinal disruption or retinal folds wereobserved in at least 1 eye from Groups 1, 3, 4 and 5. These could beretinal invaginations due to needle injection. A very small retinaldetachment measuring 100 microns in length is present in one eye at thelocation of the small retinal disruption (Group 3). No other retinaldetachments were noted in any eye from any group.

A focus of mild histiocytic and multi-nucleated inflammation wasobserved around a small displaced focus of lens fibers in the vitreouschamber of one eye from Group 3. This is considered lens-inducedgranulomatous endophthalmitis, and may be due to a slight nick of thelens by the needle at injection. No other such lesions were observed inany eye from any group.

Example 8: Additional Examples

In certain embodiments, the present invention also relates to implantsas disclosed herein that contain a high amount of TKI such as axitinib,such as a dose of axitinib of more than about 1200 μg, or more thanabout 1800 μg. Certain exemplary prophetic implants containing such ahigh dose of axitinib are disclosed in the following Table 29.

TABLE 29 Prophetic implants containing a high dose of axitinib (i.e.,above 1200 μg) Implant type Implant #1 Implant #2 Implant #3 Implant #4Formulation Axitinib 68.6% 68.6% 68.6% 68.6% (% dry Dose 1580 ug 2360 ug6010 ug 8990 ug basis w/w) PEG Hydrogel 26.0% 26.0% 26.0% 26.0% 4a20KPEG-SAZ 17.4% 17.4% 17.4% 17.4% 8a20K PEG-NH2 8.7% 8.7% 8.7% 8.7% Sodiumphosphate 5.4% 5.4% 5.4% 5.4% Formulation Axitinib 16.5% 16.5% 16.5%16.5% (% wet PEG Hydrogel 6.3% 6.3% 6.3% 6.3% basis w/w) 4a20K PEG-SAZ4.2% 4.2% 4.2% 4.2% 8a20K PEG-NH2 2.1% 2.1% 2.1% 2.1% Sodium phosphate1.3% 1.3% 1.3% 1.3% WFI 75.9% 75.9% 75.9% 75.9% Axitinib per final 145.0ug/mm 145.0 ug/mm 551.4 ug/mm 551.4 ug/mm dry length Approximate 23033440 8761 13105 Implant Mass (dose ug/API %) Configuration StretchingMethod Wet Wet Wet Wet (Stretch Factor) (2.1) (2.1) (2.1) (2.1) NeedleSize 22G ETW 22G ETW 17G ETW 17G ETW (0.522 mm ID) (0.522 mm ID) (1.24mm ID) (1.24 mm ID) Injector/Syringe Implant Implant Implant ImplantInjector Injector Injector Injector Packaging Foil Pouches Foil PouchesFoil Pouches Foil Pouches Sterilization Type Gamma Gamma Gamma GammaSite Storage Refrigerated Refrigerated Refrigerated RefrigeratedDimensions Dried Diameter 0.49 mm 0.49 mm 0.97 mm 0.97 mm Length 10.9 mm16.3 mm 10.9 mm 16.3 mm Volume 2.1 mm³ 3.1 mm³ 8.0 mm³ 12.0 mm³ ImplantMass 2.3 mg 3.4 mg 8.8 mg 13.1 mg Hydrated Diameter 1.0 mm 1.0 mm 2.0 mm2.0 mm Length 10.0 mm 15.0 mm 10.0 mm 15.0 mm

1-30. (canceled)
 31. A method of treating an ocular disease in a patientin need thereof, the method comprising administering to the patient asustained release biodegradable ocular implant comprising a hydrogel anda dose of axitinib from about 150 μg to about 1200 μg, wherein theaxitinib is dispersed within the hydrogel, and wherein the implant inits dry state prior to implantation is cylindrical; has a length ofabout 6 mm to about 17 mm and a diameter of 0.2 mm to 0.5 mm; and has atotal implant weight of about 0.2 mg to about 1.5 mg.
 32. The method ofclaim 31, wherein the implant comprises axitinib in an amount of about480 μg to about 750 μg.
 33. The method of claim 31, wherein the implantcomprises axitinib in an amount of about 160 μg to about 250 μg.
 34. Themethod of claim 31, wherein the implant in its dry state has a totalweight of about 0.4 mg to about 1.2 mg.
 35. The method of claim 31,wherein the implant is cylindrical and in its hydrated state (after 24hours in phosphate-buffered saline at a pH of 7.2 at 37° C.) has alength of about 6 mm to about 9 mm and a diameter of equal to or lessthan about 0.8 mm.
 36. The method of claim 31, wherein the implant iscylindrical and has a ratio of the diameter in the hydrated state to thediameter in the dry state of less than about
 5. 37. The method of claim31, wherein the implant is cylindrical and has a ratio of the length inthe dry state to the length in the hydrated state of greater than about0.7.
 38. The method of claim 31, wherein the implant provides for therelease of axitinib at an average rate of about 0.25 μg to about 2.5 μgper day in phosphate-buffered saline at a pH of 7.2 and 37° C. for aperiod of 30 days under non-sink simulated physiological conditions. 39.The method of claim 31, wherein the implant provides for the release ofaxitinib for a period from about 3 months to about 38 months afteradministration.
 40. The method of claim 31, wherein the implant providesfor the release of axitinib for a period of about 6 to about 9 monthsafter administration.
 41. The method of claim 31, wherein the hydrogelcomprises polyethylene glycol (PEG) units.
 42. The method of claim 41,wherein the hydrogel comprises PEG units that have a number averagemolecular weight of about 20,000 Daltons.
 43. The method of claim 41,wherein the hydrogel comprises crosslinked PEG units and the crosslinksbetween the PEG units include a group represented by the followingformula

wherein m is an integer from 0 to
 10. 44. The method of claim 43,wherein m is
 6. 45. The method of claim 43, wherein the PEG unitscomprise 4-arm and/or 8-arm PEG units.
 46. The method of claim 31,wherein the axitinib is in the form of particles having a d90 particlesize of less than about 30 μm as determined by laser diffraction. 47.The method of claim 31, wherein the implant in its dry state containsfrom about 200 μg to about 900 μg axitinib per mm³.
 48. The method ofclaim 31, wherein the implant in its dry state contains from about 60%to about 75% by weight axitinib and from about 21% to about 31% byweight PEG units (dry composition).
 49. The method of claim 31, whereinthe implant in its dry state contains from about 45% to about 55% byweight axitinib and from about 37% to about 47% by weight PEG units (drycomposition).
 50. The method of claim 31, wherein the ocular disease isa retinal disease.
 51. The method of claim 50, wherein the retinaldisease is selected from neovascular age-related macular degeneration,diabetic macular edema, diabetic retinopathy, retinal vein occlusion,choroidal neovascularization, acute macular neuroretinopathy, centralserous chorioretinopathy, cystoid macular edema or a combinationthereof.
 52. The method of claim 50, wherein the retinal disease isneovascular age-related macular degeneration.
 53. The method of claim50, wherein the retinal disease is diabetic macular edema or diabeticretinopathy.
 54. The method of claim 50, wherein the retinal disease isretinal vein occlusion.
 55. The method of claim 31, wherein the implantis injected by a needle for injection.
 56. The method of claim 55,wherein the needle for injection is a needle that has a gauge size of 22to
 30. 57. The method according to claim 31, wherein concurrently or incombination with the treatment with the sustained release ocular implantan anti-VEGF agent is administered to the patient.
 58. The method ofclaim 57, wherein an anti-VEGF agent is administered in combination withthe implant, and is administered within about 1, about 2 or about 3months from the administration of the implant.
 59. The method of claim57, wherein the anti-VEGF agent is selected from the group consisting ofaflibercept, bevacizumab, pegaptanib, ranibizumab, and brolucizumab andis administered by intravitreous injection.
 60. The method of claim 31,wherein the implant is administered by injection into the vitreous humorand the axitinib dose administered per eye once during a treatmentperiod of at least 3 months is from about 480 μg to about 750 μgaxitinib and is contained in one implant.